Esketamine for the treatment of depression

ABSTRACT

The present invention provides methods for treating depression in a patient, comprising administering to the patient in need of the treatment a therapeutically effective amount of esketamine. In some embodiments, the depression is major depressive disorder or treatment resistant depression. In other embodiments, the therapeutically effective amount is clinically proven safe and/or effective. Also provided are methods to mitigate the risk or misuse or abuse of esketamine, instructions for use of the esketamine product, and methods for selling a drug product containing esketamine.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.17/436,188, filed Sep. 3, 2021, which is a US national stage ofInternational Patent Application No. PCT/IB2020/051344, filed Feb. 18,2020, which claims the benefit of U.S. Provisional Patent Application62/813,767, filed Mar. 5, 2019, and U.S. Provisional Patent ApplicationNo. 62/814,274, filed Mar. 5, 2019, the disclosures of which areincorporated by reference herein.

FIELD OF THE INVENTION

The present invention is directed to pharmaceutical products, and tomethods for the treatment of depression (e.g., major depressivedisorder). In some embodiments, the methods are useful for the treatmentof treatment-refractory or treatment-resistant depression. In otherembodiments, the methods are useful for the treatment of suicidalideation. The invention comprises administering to a patient in needthereof a clinically proven safe and therapeutically effective amount ofesketamine as mono-therapy or as combination therapy with at least oneantidepressant.

BACKGROUND OF THE INVENTION

Major depressive disorder (MDD) affects about 7-15% of the generalpopulation. MDD is associated with significant morbidity and mortalityand the leading cause of disability worldwide. About one third ofpatients fail to achieve remission despite treatment with multipleantidepressant medications, and are considered to have treatmentresistant depression (TRD). Such patients who do benefit with oral ADshave high rates of relapse even with continuation of treatment.

The impact of TRD on patient's lives is difficult to adequatelydescribe. Many patients have depressive episodes lasting years. Severelydepressed patients lose the will to carry on with their lives, there isa 7-fold increase in suicide attempts. Life expectancy is lowered by 10years. In extreme cases they cannot even engage in basic self-careactivities such as bathing or eating, or taking care of themselves,leave alone those in their care as a parent, spouse etc. This impactsnot only the patient themselves, but also the family and those dependanton them. They also lose the ability to experience pleasure in doing thethings that used to enjoy, which robs people of the essence of life andwhat drives it. In effect their lives are taken away from them by TRD.These effects are theorized to be related to dysregulation of theglutamate pathway.

Glutamate is the major excitatory neurotransmitter in the mammalianbrain and has a prominent role in synaptic plasticity, learning andmemory. At elevated levels, glutamate is a potent neuronal excitotoxinthat may provoke rapid or delayed neurotoxicity. Over the years, therehas been a growing interest in the role of glutamate in thepathophysiology of depression since abnormal activity of theglutamatergic system probably contributes to the impairment of synapticplasticity observed in depressed patients. Ketamine, a classicanesthetic drug, showed activity not only in animal models of depressionbut also in small scale clinical studies in patients with majordepressive disorder including subjects with treatment-resistantdepression. At low, subanesthetic doses administered by intravenousinfusion, ketamine showed a robust antidepressant effect in patientsthat lasted for a few days after a single dose and could be maintainedfor several weeks via repeated infusions.

Ketamine (a racemic mixture of the corresponding S- and R-enantiomers)is a nonselective antagonist at the phencyclidine binding site of theglutamate N-methyl-D-aspartate (NMDA) receptor, although this may notprimarily mediate the antidepressant effect. The enantiomer S-ketamine(esketamine) displays approximately 3 to 4 fold greater affinity for theglutamate NMDA receptor in vitro than R-ketamine. A major concernassociated with ketamine and esketamine is the potential forneurotoxicity associated with long-term use and whether repeated dosesof ketamine/esketamine in the longer term can maintain a significantantidepressant effect (Molero, et al., “Antidepressant Efficacy andTolerability of Ketamine and Esketamine: A Critical Review,” CNS Drugs(2018) 32:411-420). In particular, previous studies indicated thatesketamine, in contrast to R-ketamine, could not elicit a sustainedantidepressant effect in a rodent model (C. Yang et al., “R-Ketamine: arapid onset and sustained antidepressant without psychotomimetic sideeffects,” Transl. Psychiatry (2015) 5:1-11). Moreover, esketamine showedgreater undesirable psychotomimetic side effects compared withR-ketamine, including a significant reduction in PV-positive cells inthe brain that is associated with psychosis and cognitive impairment(id.). The literature does not provide guidance concerning thecumulative effect or tolerability of long term dosing of esketamine.

There remains a need to provide an effective, long-term and safetreatment for depression, particularly in patients diagnosed as havingtreatment-refractory or treatment-resistant depression.

SUMMARY OF THE INVENTION

The present invention is directed to methods for the treatment ofdepression (e.g., major depressive disorder), comprising administeringto a patient in need thereof, a clinically proven safe andtherapeutically effective amount of esketamine.

The present invention is further directed to a method for the treatmentof depression (e.g., major depressive disorder), comprisingadministering to a patient in need thereof, combination therapy with aclinically proven safe and therapeutically effective amount ofesketamine and at least one antidepressant, as herein defined.

The present invention also is directed to methods of maintaining stableremission or stable response achieved by a patient with depressionfollowing administration of a therapeutically effective amount ofesketamine during an initial administration phase, comprising continuingadministration of a therapeutically effective amount of esketamine forat least five months during a subsequent administration phase. In someembodiments, the depression is major depressive disorder or treatmentresistant depression.

The present invention further is directed to methods for the long termtreatment of depression in a patient, comprising administering to thepatient in need of treatment a clinically proven safe and/or clinicallyproven effective therapeutically effective amount of esketamine for atleast six months. In some embodiments, the depression is majordepressive disorder or treatment resistant depression.

The method of treatment includes long term treatment, includingdurations of at least about six months. In some embodiments, thetreatment may be a duration of at least about one year, at least about18 months, or at least about two years. For example, long term treatmentmay include a duration range of about six months to about two years. Thetreatment may extend for much longer periods of time to the extent thatthe patient is benefiting from the therapy.

In some embodiments, the at least one antidepressant is independentlyselected from the group consisting of mono-amine oxidase inhibitors,tricyclics, serotonin reuptake inhibitors, serotonin noradrenergicreuptake inhibitors, noradrenergic and specific serotonergic agents,noradrenaline reuptake inhibitors, natural products, dietarysupplements, neuropeptides, compounds targeting neuropeptide receptorsand hormones.

In other embodiments, methods for the treatment of depression (e.g.,major depressive disorder) are provided and comprise administering to apatient in need thereof a clinically proven safe and therapeuticallyeffective amount of esketamine in combination with one or more compoundsselected from the group consisting of mono-amine oxidase inhibitors(MAOI) such as irreversible MAOI (phenelzine, tranylcypromine),reversible (MOAI) moclobemide, and the like; tricyclics such asimipramine, amitriptyline, desipramine, nortriptyline, doxepin,protriptyline, trimipramine, domipramine, amoxapine, and the like;tetracyclics such as maprotiline, and the like; non-cydics such asnomifensine, and the like; triazolopyridines such as trazodone, and thelike; anticholinergics e.g. scopolamine; serotonin reuptake inhibitorssuch as fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine, andthe like; serotonin receptor antagonists such as nefazadone, tianeptineand the like; serotonin noradrenergic reuptake inhibitors such asvenlafaxine, des-venlafaxine, milnacipran, levo-milnacipran, and thelike; noradrenergic and specific serotonergic agents such asmirtazapine, and the like; noradrenaline reuptake inhibitors such asreboxetine, and the like; atypical antipsychotics such as bupropion andthe like, and the like; lithium, triple reuptake inhibitors, naturalproducts such as Kava-Kava, St. John's Wort, and the like; dietarysupplements such as s-adenosylmethionine, and the like; andneuropeptides such as thyrotropin-releasing hormone and the like, andthe like; compounds targeting neuropeptide receptors such as neurokininreceptor antagonists and the like; and hormones such astriiodothyronine, and the like.

In other embodiments, methods for the treatment of depression (e.g.,major depressive disorder) are provided and comprise administering to apatient in need thereof a clinically proven safe and therapeuticallyeffective amount of esketamine in combination with one or more compoundsselected from the group consisting of mono-amine oxidase inhibitors;tricyclics; tetracyclics; non-cyclics; triazolopyridines; serotoninreuptake inhibitors; serotonin receptor antagonists; serotoninnoradrenergic reuptake inhibitors; serotonin noradrenergic reuptakeinhibitors; noradrenergic and specific serotonergic agents;noradrenaline reuptake inhibitors; atypical antipsychotics; naturalproducts; dietary supplements; neuropeptides; compounds targetingneuropeptide receptors; and hormones. Preferably, esketamine isadministered in combination with one or more compounds selected from thegroup consisting of mono-amine oxidase inhibitors, tricyclics, serotoninreuptake inhibitors, serotonin noradrenergic reuptake inhibitors,noradrenergic and specific serotonergic agents, atypical antipsychotics,and/or adjunctive therapy with antipsychotic medication (e.g.risperidone, olanzapine, quetiapine, aripiprazole and ziprasidone). Morepreferably, esketamine is administered in combination with one or morecompounds selected from the group consisting of mono-amino oxidaseinhibitors, tricyclics, serotonin reuptake inhibitors, and serotoninnorepinephrine reuptake inhibitors. More preferably, esketamine isadministered in combination with one or more compounds selected from thegroup consisting of serotonin reuptake inhibitors and serotoninnorepinephrine reuptake inhibitors.

In yet further embodiments, methods for the treatment of depression(e.g., major depressive disorder) are provided and compriseadministering to a patient in need thereof a clinically proven safe andtherapeutically effective amount of esketamine in combination with oneor more compounds selected from the group consisting of phenelzine,tranylcypromine, moclobemide, imipramine, amitriptyline, desipramine,nortriptyline, doxepin, protriptyline, trimipramine, domipramine,amoxapine, fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine,venlafaxine, milnacipran, mirtazapine, bupropion, thyrotropin-releasinghormone and triiodothyronine.

Preferably, esketamine is administered in combination with one or morecompounds selected from the group consisting of lithium, riluzole,phenelzine, tranylcypromine, moclobemide, imipramine, amitriptyline,desipramine, nortriptyline, doxepin, protriptyline, trimipramine,domipramine, amoxapine, fluoxetine, sertraline, paroxetine, citalopram,fluvoxamine, venlafaxine, milnacipran, levomilnacipran, mirtazapine andbupropion. More preferably, esketamine is administered in combinationwith one or more compounds selected from the group consisting ofphenelzine, tranylcypromine, moclobemide, imipramine, amitriptyline,desipramine, nortriptyline, doxepin, protriptyline, trimipramine,clomipramine, amoxapine, fluoxetine, sertraline, paroxetine, citalopramand fluvoxamine. More preferably, esketamine is administered incombination with one or more compounds selected from the groupconsisting of fluoxetine, sertraline, paroxetine, citalopram,escitalopram and fluvoxamine.

In still further embodiments, methods for the treatment of depression(e.g., major depressive disorder) are provided and compriseadministering to a patient in need thereof a clinically proven safe andtherapeutically effective amount of esketamine in combination with oneor more compounds selected from the group consisting of neuropeptidessuch as thyrotropin-releasing hormone and the like; compounds targetingneuropeptide receptors such as neurokinin receptors antagonists and thelike; and hormones such as triiodothyronine and the like.

In other embodiments, methods for the treatment of depression (e.g.,major depressive disorder) are provided and comprise administering to apatient in need thereof, combination therapy with a clinically provensafe and therapeutically effective amount of esketamine, at least oneantidepressant, and at least one atypical antipsychotic, as hereindefined.

In further embodiments, methods for the treatment of depression (e.g.,major depressive disorder) are provided and comprise administering to apatient in need thereof, combination therapy with a clinically provensafe and therapeutically effective amount of esketamine, at least oneantidepressant, and at least one atypical antipsychotic selected fromthe group consisting of quetiapine, aripiprazole, brexpiprazole,olanzapine, lurasidone, risperidone and paliperidone.

In other embodiments, the methods for treatment of depression may becombined with adjunctive therapies such as anti-psychotic therapy,electroconvulsive therapy (ECT), transcranial magnetic stimulation(TMS), or combinations thereof.

The present invention is further directed to uses of esketamine in thepreparation of a medicament for treating depression (e.g., majordepressive disorder) in a patient in need thereof. In some embodiments,the medicament is for treating treatment-refractory ortreatment-resistant depression. In other embodiments, the medicament isfor treating suicidal ideation.

The present invention is further directed to esketamine for use in amethod for the treatment of depression (e.g., major depressivedisorder), preferably treatment-refractory or treatment-resistantdepression, in a subject in need thereof.

In another embodiment, compositions comprising esketamine for thetreatment of depression (e.g., major depressive disorder) are provided.In some embodiments, the compositions are for the treatment oftreatment-refractory or treatment-resistant depression. In otherembodiments, the medicament is for treating suicidal behavior and/orsuicidal ideation.

The present invention is also directed to methods of treatingdepression, comprising administering an approved drug product containingesketamine to a subject with depression in an amount that is describedin a drug product label for the approved drug product.

The present invention is further directed to methods of selling anapproved drug product comprising esketamine, said method comprisingselling such drug product, wherein a drug product label for a referencelisted drug for such drug product includes instructions for treatingdepression.

The present invention also is directed to methods of offering for sale adrug product comprising esketamine, said method comprising offering forsale such drug product, wherein a drug product label for a referencelisted drug for such drug product includes instructions for treatingdepression.

The present invention is further directed to approved drug products withat least one approved indication, wherein said approved drug productcomprises esketamine.

The present invention also is directed to methods of using the approvedproduct described herein, wherein the approved product comprises one ormore intranasal spray devices, the one or more devices comprise theesketamine, and the one or more devices is configured to administer fromabout 28 to about 84 mg of esketamine.

The present invention is further directed to methods to mitigate therisk of misuse or abuse of esketamine, comprising restrictingdistribution of an approved esketamine drug product to selecteddistributors, wherein the distributors are Drug EnforcementAdministration registered and deliver the approved esketamine drugproduct only to a pre-approved site of care.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 illustrates a schematic of the study design of the ESKETINTRD3002Phase 3 clinical trial.

FIG. 2 illustrates the least squares mean changes (±SE) in MADRS totalscore over time observed case MMRM during the double-blind inductionphase. LS mean and SE were based on MMRM with change from baseline asthe response variable and the fixed effect model terms for treatment(intranasal esketamine+oral AD, oral AD+ intranasal placebo), day,country, class or oral antidepressant (SNRI or SSRI), andtreatment-by-day, and baseline value as a covariate. Negative change inscore indicated improvement. *1-sided p<0.025.

FIG. 3 is a bar graph of the response rates on day 2; a response is a≤50% improvement on MADRS from baseline for patients taking esketamineand an oral antidepressant.

FIG. 4 is a bar graph of the response rates on day 28; a response is a≤50% improvement on MADRS from baseline for patients taking esketamineand an oral antidepressant.

FIG. 5 is a bar graph of the remission rates on day 28; remission is aMADRS total score of ≤12.

FIG. 6 is a bar graph showing the percent of subjects reporting problems(levels 2 through 5) with mobility, self-care, activities, pain, andanxiety/depression.

FIG. 7 illustrates the arithmetic mean (±SE) for systolic blood pressureover time during the double-blind induction phase using the safetyanalysis set.

FIG. 8 illustrates the arithmetic mean (±SE) for diastolic bloodpressure over time; double-blind induction phase using the safetyanalysis set.

FIG. 9 illustrates the clinician-assessed dissociative symptom scale(CADSS), total score over time during the double-blind phase using thesafety analysis set.

FIG. 10 illustrates the arithmetic mean (±SE) modified observer'sassessment of alertness/sedation (MOAA/S) score over time; double-blindinduction phase using the safety analysis set.

FIG. 11 illustrates the Least Square mean change in total MADRS scoreover time (observed cases) in US patients with TRD.

FIG. 12 illustrates patient-rated severity of depressive illness(observed cases) in US patients with TRD, as assessed with the PHQ-9.

FIG. 13 illustrates functional impairment (observed case) in US patientswith TRD, as assessed with SDS.

FIG. 14 illustrates the percentage of US patients with TRD achieving aresponse 4 weeks post initial dose (observed case).

FIG. 15 illustrates the percentage of US patients with TRD achievingclinician-rated remission 4-weeks post initial dose.

FIG. 16 illustrates the frequency distribution of PHQ-9 severitycategories (observed case) in US patients with TRD.

FIG. 17 illustrates the percentage of US patients with TRD who had21-point decrease in the CGI-S (observed case) 4-weeks post initialdose.

FIG. 18 illustrates a schematic to the study design of theESKETINTRD3005 Phase 3 clinical trial.

FIG. 19 illustrates the least squares mean changes (±SE) in MADRS totalscore over time observed case MMRM; double-blind induction phase (studyESKETINTRD3005: full analysis set).

FIG. 20 illustrates that arithmetic mean (t SE) systolic blood pressureover time during the double-blind induction phase using theESKETINTRD3005 safety analysis set.

FIG. 21 illustrates that arithmetic mean (±SE) diastolic blood pressureover time during the double-blind induction phase using theESKETINTRD3005 safety analysis set.

FIG. 22 is a plot of CADSS total score over time during the double-blindphase using the safety analysis set.

FIG. 23 illustrates the least squares mean changes (t SE) in MADRS totalscore over time LOCF ANCOVA during the double-blind induction phaseusing the full analysis set. LS Mean and SE were based on analysis ofcovariance (ANCOVA) model with change from baseline as the responsevariable and factors for treatment (intranasal esk+oral AD, oral AD+intranasal placebo), region, and class of oral antidepressant (SNRI orSSRI), and baseline value as a covariate. Results are not adjusted forsample size re-estimation. Negative change in score indicatesimprovement.

FIG. 24 illustrates the forest plot for MADRS total score showing theleast squares mean treatment difference of change from baseline (95%Confidence Interval) to day 28 MMRM by Subgroup during the double-blindinduction phase using the full analysis set. Subgroups with fewer than 5subjects not presented. Results are not adjusted for sample sizere-estimation.

FIG. 25 illustrates the arithmetic mean changes (±SE) in MADRS totalscore over time observed case for the age 65-74 group during thedouble-blind induction phase using the full analysis set.

FIG. 26 illustrates the arithmetic mean changes (±SE) in MADRS totalscore over time observed case for the age ≤75 group during thedouble-blind induction phase using the full analysis set.

FIG. 27 illustrates the least squares mean changes (±SE) in MADRS totalscore over time (observed cases) MMRM for Stage 1 during thedouble-blind induction phase using the full analysis set. LS Mean and SEwere based on mixed model for repeated measures (MMRM) with change frombaseline as the response variable and the fixed effect model terms fortreatment (intranasal esk+oral AD, oral AD+ intranasal placebo), day,region, class of oral antidepressant (SNRI or SSRI), andtreatment-by-day, and baseline value as a covariate. Results are notadjusted for sample size re-estimation. Negative change in scoreindicates improvement.

FIG. 28 illustrates the least squares mean changes (±SE) in MADRS totalscore over time (observed cases) MMRM for stage 2 during thedouble-blind induction phase using the full analysis set. S Mean and SEwere based on mixed model for repeated measures (MMRM) with change frombaseline as the response variable and the fixed effect model terms fortreatment (intranasal esk+oral AD, oral AD+ intranasal placebo), day,region, class of oral antidepressant (SNRI or SSRI), andtreatment-by-day, and baseline value as a covariate. Results are notadjusted for sample size re-estimation. Negative change in scoreindicates improvement.

FIG. 29 illustrates that least squares mean change in MADRS total scoreover time (observed cases) in US patients aged 2:65 years with TRD.MADRS total score ranges from 0 to 60; a higher score indicates a moresevere condition.

FIG. 30 illustrates that frequency distribution of illness severitybased on CGI-S scores at baseline and double-blind phase endpoint(LOCF). CGI-S score ranges from 1 (normal, not at all ill) to 7 (amongthe most extremely ill patients). CGI-S score ranged from 1 (normal, notat all ill) to 7 (among the most extremely ill patients).

FIG. 31 illustrates the percentage of US patients aged ≤65 years withTRD achieving response (observed case), as assessed by MADRS.Clinician-rated response a was defined as a 250% decrease from baselinein MADRS total score.

FIG. 32 illustrates the percentage of US patients aged ≤65 years withTRD achieving remission (observed case), as assessed by MADRS.Clinician-rated remission was defined as a MADRS total score of ≤12.

FIG. 33 illustrates the percentage of US patients aged 65 years with TRDachieving patient-rated remission (observed case), as assessed by PHQ-9.

FIG. 34 illustrates the percentage of US patients aged 65 years with TRDwho had a clinically meaningful response, as assessed by CGI-S.

FIG. 35 illustrates the percentage of US patients aged 65 years with TRDwho had a clinically significant response, as assessed by CGI-S.Clinically meaningful and clinically significant responses were definedas a 21-point or a 2-point decrease in CGI-S from baseline,respectively.

FIG. 36 illustrates the frequency distribution of illness severity basedon clinical global impression-severity (CGI-S) scores at baseline anddouble-blind phase endpoint.

FIG. 37 shows the study design for evaluate the efficacy and safety ofintranasal esketamine for the rapid reduction of the symptoms of majordepressive disorder, including suicidal ideation, in subjects assessedto be at imminent risk for suicide.

FIG. 38 shows least-square mean changes (±SE) from baseline for theMADRS total score over time in the double-blind phase using lastobservation carried forward data. LS Mean and SE was based on analysisof covariance (ANCOVA) model with treatment (placebo, esketamine 84 mg),antidepressant therapy (AD monotherapy, AD plus augmentation therapy)and analysis center as factors, and baseline value as a covariate.

FIG. 39 shows the mean changes (SE) in CGJSR from baseline to 4 and 24hours. Mean change and SE were based on ranks of change from baseline(LOCF) data and analyzed using an ANCOVA model with treatment, analysiscenter, and SoC as fixed effects and baseline value (unranked as acovariate).

FIG. 40 correlates the percentage of patients with the resolution ofsuicide risk at 4 and 24 hours.

FIG. 41 shows the frequency distribution of SIBAT scores at double-blindbaseline, Day 1:4-hours postdose, double-blind endpoint, and follow-upendpoint. Clinical global judgment of suicide risk scores range from 0to 6. 0: Not suicidal; 1: Occasional suicidal ideas present, but nospecial intervention required; 2: Some clear suicidal ideas present;patient is encouraged to schedule professional contacts as needed; 3:Suicidal risk requires a scheduled outpatient follow-up; but no otherimmediate intervention: 4: Suicidal risk requires immediateintervention, but not hospitalization (e.g., medication, urgentoutpatient follow-up); 5: Suicidal risk requires immediatehospitalization, but without suicide precautions; 6: Suicidal riskrequires hospitalization with suicide precautions.

FIG. 42 shows the least-square mean changes (SE) from baseline in MADRSscore to 4 hours (primary endpoint) and about 24 hours.

FIG. 43 correlates the percentage of patients with their respectiveMADRS response and remission at days 1, 2 and endpoint.

FIG. 44 correlates the percentage of patients having remission at DBendpoint and during follow-up.

FIG. 45 shows least-square mean changes (t SE) from baseline for the BSStotal score over time in the double-blind phase using last observationcarried forward data.

FIGS. 46 and 47 present means for blood pressure over time by treatmentgroup in the double-blind phase.

FIG. 48 is a plot of CADSS total score over time during the double-blindphase (Study ESKETINSUI2001: Safety Analysis Set).

FIG. 49 is the trial design for Example 4.

FIG. 50 is a flowchart summarizing the subject and treatment informationof Example 4.

FIG. 51 shows the cumulative proportion of subjects who remained relapsefree; maintenance phase (Kaplan-Meier estimates) (full (stableremitters) analysis set) for Example 4.

FIG. 52 shows the cumulative proportion of subjects who remained relapsefree; maintenance phase (Kaplan-Meier estimates) (full (stableresponders) analysis set) for Example 4.

FIG. 53 shows the arithmetic mean (±SE) systolic blood pressure overtime; maintenance phase (safety (MA) analysis set) for Example 4.

FIG. 54 shows the arithmetic mean (±SE) diastolic blood pressure overtime; maintenance phase (safety (MA) analysis set) for Example 4.

FIG. 55 shows the arithmetic mean (±SE) CADSS total score over time;maintenance phase (safety (MA) analysis set) for Example 4.

FIG. 56 is a forest plot of hazard ratio by subgroup: Cox Regression(full (stable remitters) analysis set) for Example 4. Hazard ratioestimates for subgroups with no event in either arm not displayed.Subgroups with fewer than 5 subjects not presented.

FIG. 57 is the trial design for Example 5. At entry to the trial,transferred entry non-responder subjects continued to receive the sameoral antidepressant initiated in the ESKETINTRD3005 study. The new oralAD is for direct entry subjects only.

FIG. 58 is shows the frequency distribution for the CGI-S of Example 5.

FIG. 59 shows the arithmetic mean (±SE) of detection—attention (simplereaction time) (all enrolled analysis set) for the age group ≥65 yearsin Example 5.

FIGS. 60-62 shows the level of impairment for the EQ-5D-5L by measuringanxiety/depression, usual activities, and pain/discomfort, respectively.

FIG. 63 shows the arithmetic mean (±SE) systolic blood pressure overtime; induction and optimization/maintenance phases (all enrolledanalysis set) for Example 5.

FIG. 64 shows the arithmetic mean (±SE) diastolic blood pressure overtime; induction and optimization/maintenance phases (all enrolledanalysis set) for Example 5.

FIG. 65 is a plot of CADSS total score over time during the inductionand optimization/maintenance phase (all enrolled analysis set) forExample 5.

FIG. 66 is a plot showing the mean (t) SE for the of the briefpsychiatric rating positive symptom subscale total score over timeduring the induction and optimization/maintenance phases (all enrolledanalysis set) for Example 5.

FIG. 67 shows means for the MADRS total score over time in the IND andOP/MA phases based on observed case data for Example 5.

FIG. 68 shows the response for patients having a response with a ≤50%reduction from baseline and a remission with a MADRS of ≤12.

FIG. 69 shows means for the PHQ-9 total score over time in the IND andOP/MA phases based on observed case data for Example 5.

FIG. 70 is an illustration of decreased and increased activity.MK-801-induced changes in activity are described in Section 3.3 ofExample 6. Gross pathology did not reveal any tissue changes.

FIG. 71A to FIG. 71C shows a repeated dose neurotoxicity study.Haematoxylin-eosin (HE) stained retrosplenial cortex shows the absenceof neuronal necrosis in an esketamine HCl-treated rat (54 mg/day) andits presence in an (+)MK-801 maleate-treated rat as described in Example6. FIG. 71A is an image of the retrosplenial cortex of an esketamineHCl-treated rat (54 mg/day) showing the absence of neuronal necrosis.FIG. 71B is an image of the retrosplenial cortex from an (+)MK-801maleate-treated animal. Arrows show necrotic neurons (shrunken,eosinophilic cytoplasm with condensed nuclei). FIG. 71C is an image of ahigher power view of the necrotic neurons (arrows) in the retrosplenialcortex from an (+)MK-801maleate treated animal.

FIG. 72A and FIG. 72B illustrate[[s]] a repeated dose neurotoxicitystudy. Fluoro-Jade (FJ) stained retrosplenial cortex shows the absenceof neuronal necrosis in an esketamine HCl-treated rat (54 mg/day) andits presence in an (+)MK-801 treated rat as described in Example 6. FIG.72A is an image of the retrosplenial cortex of an esketamine HCl-treatedrat (54 mg/day) showing the absence of neuronal necrosis. FIG. 72B is animage of the retrosplenial cortex from an (+)MK-801 maleate-treatedanimal.

FIG. 73 is a flowchart showing the disposition of patients of Example 7.Seven participants started the follow-up phase earlier than day 74,having received 2 weeks of study drug during the open-label phase of thestudy.

FIGS. 74A and 74B are line graphs showing the mean change (±SE) in MADRStotal score over time in double blind phase of Example 7. Changes areshown in periods 1(A) and 2(B). Period 2 consisted only of participantswho had received placebo in period 1 and had moderate to severe symptoms(n=28). Period 1 (days 1-8) and period 2 (days 8-15) are discussed inthe Design section of the Methods and shown in the vertical axis of FIG.73. BL indicates baseline; 2H, 2 hours post dose. Error bars indicateSE. Period 2 consists only of those participants who had been on placeboin Period 1 and had moderate-to-severe symptoms (n=28).

FIG. 75 is a line graph showing the MADRS total score mean change frombaseline to follow-up endpoint for participants who entered theopen-label phase of Example 7. Period 1 (days 1-8), period 2 (days8-15), open-label period (days 15-74), and the follow-up period (days74-130) are discussed in the Design section of the Methods and shown inthe vertical axis of FIG. 73. BL indicates baseline; error bars, SE.

FIGS. 76A and 76B are line graphs showing the mean (±SE) MADRS totalscore over time in the double-blind phase of Example 7. Period 2consists only of those participants who had been on placebo in Period 1and had moderate-to-severe symptoms (n=28). At the 2-hour time point,modified MADRS was used, with baseline scores for sleep and appetiteitems carried forward.

FIG. 77 is a plot of mean systolic blood pressure over time by periodfor participants who received the same treatment for both periods duringthe double-blind phase in Example 7.

FIG. 78 is a plot of mean diastolic blood pressure over time by periodfor participants who received the same treatment for both periods duringthe double-blind phase in Example 7.

FIG. 79 is a plot of mean CADSS total score over time for participantswho received the same treatment for both periods in Example 7.

FIG. 80 is a plot of the mean plasma concentration-time profile ofesketamine.

FIG. 81 is a plot of the mean plasma concentration-time profile ofnoresketamine.

FIGS. 82A and 82B are C_(max) vs. dose and AUC_(last) vs. dose,respectively, for the data of Example 10. Line of regression shown forC_(max) (r=0.53) and AUC_(last) (r=0.70).

FIG. 83A to 83E depict instructions for use for an exemplary nasal spraydevice.

FIG. 84 is a flow diagram of an approved esketamine drug product throughpossible medical systems.

FIG. 85 are the administration instructions for Example 11.

FIG. 86 shows the effect of specific populations on the pharmacokineticsof esketamine.

FIG. 87 shows the effect of co-administered drugs on thepharmacokinetics of esketamine.

FIG. 88 shows the effect of esketamine on the pharmacokinetics ofco-administered drugs.

FIG. 89 is a line graph of the least squares mean change from baselinein MADRS total score over time in patients with TRD in study 1*(FullAnalysis Set)−MMRM analysis. Note: In this flexible-dose study, dosingwas individualized based on efficacy and tolerability. Few subjects(<10%) had reduction in SPRAVATO dosage from 84 mg to 56 mg twiceweekly.

FIG. 90 is a plot of the time to relapse in patients with TRD in stableremission in study 2*(Full Analysis Set). Note: The estimated hazardratio (95% CI) of SPRAVATO+Oral AD relative to Placebo nasal spray+OralAD based on weighted estimates was 0.49 (95% CI: 0.29, 0.84). However,the hazard ratio did not appear constant throughout the trial.

FIG. 91 is a plot of time to relapse in patients in stable response inTRD patients in study 2*(Full Analysis Set). Note: The estimated hazardratio (95% CI) of SPRAVATO+Oral AD relative to Placebo nasal spray+OralAD based on Cox proportional hazards model was 0.30 (95% CI: 0.16,0.55).

DETAILED DESCRIPTION OF THE INVENTION

The present invention is directed to methods for the treatment ofdepression (e.g., major depressive disorder), comprising administeringto a patient in need thereof, a clinically proven safe andtherapeutically effective amount of esketamine. In some embodiments, themethods are for the treatment of treatment refractory depression ortreatment resistant depression. In other embodiments, the medicament isfor treating suicidal ideation.

These methods advantageously permit tailoring an effective regimen topatients who have depression. Such patients include those who havealready been diagnosed with MDD, TRD, are suicidal, or have otherwisebeen untreated for depression.

Methods of maintaining stable remission or stable response achieved by apatient with depression following administration of a therapeuticallyeffective amount of esketamine during an initial administration phasealso are described. Such methods include continuing administration of atherapeutically effective amount of esketamine for at least five monthsduring a subsequent administration phase.

Thus, methods for the long term treatment of depression in a patient arealso provided. These methods comprise administering to the patient inneed of the treatment a clinically proven safe and clinically proveneffective therapeutically effective amount of esketamine for at leastsix months. Desirably, cognitive performance of the patient remainsstable, based on a baseline measurement, following six months oftreatment. In some embodiments, the treatment may be a duration of atleast about one year, at least about 18 months, or at least about twoyears. For example, long term treatment may include a duration range ofabout six months to about two years. Treatment may also be continued forlonger periods of time including, without limitation, 4, 5, 6, 7, 8, 9,10, or longer years, as determined by the attending physician. In someembodiments, the esketamine is initially dosed twice a week for up tofour weeks during an induction phase, and, thereafter, dosed lessfrequently than twice a week.

In certain embodiments of the present invention, esketamine may beadministered in combination with one or more antidepressants, as hereindescribed, preferably in combination with one to three antidepressants,more preferably in combination with one to two antidepressants.

In certain embodiments of the present invention, esketamine may beadministered in combination with one or more antidepressants, andfurther in combination with one or more atypical antipsychotics, hereindescribed.

In an embodiment, the present invention is directed to combinationtherapy comprising esketamine and one or more antidepressants; whereinthe esketamine is administered as acute treatment. In anotherembodiment, the present invention is directed to combination therapycomprising esketamine and one or more antidepressants wherein theesketamine is administered as acute treatment and wherein the one ormore antidepressants are administered as chronic treatment.

In other embodiments, such as during an induction phase, the esketaminemay be used as a mono-therapy and not in combination with any otheractive compounds.

Some of the quantitative expressions given herein are not qualified withthe term “about”. It is understood that whether the term “about” is usedexplicitly or not, every quantity given herein is meant to refer to theactual given value, and it is also meant to refer to the approximationto such given value that would reasonably be inferred based on theordinary skill in the art, including approximations due to theexperimental and/or measurement conditions for such given value.

As used herein, unless otherwise noted, the term “esketamine” shall meanthe (S)-enantiomer of ketamine, i.e., a compound of formula (I):

also known as (S)-2-(2-chlorophenyl)-2-(methylamino)cyclohexanone.“Esketamine” shall also mean a salt, e.g., a chloride salt such as thehydrochloride salt, of the (S)-enantiomer of ketamine, i.e., a compoundof formula (II):

also known as (S)-2-(2-chlorophenyl)-2-(methylamino)cyclohexanonehydrochloride.

In some embodiments, the esketamine is substantially free of the(R)-enantiomer of ketamine, i.e. a compound of formula (III):

In other embodiments, the esketamine contains less than about 10% byweight, based on the weight of the esketamine sample, of the(R)-enantiomer of ketamine. In further embodiments, the esketaminecontains less than about 10, 9, 8, 7, 6, 5, 4, 3, 2, 1, 0.5, 0.1, 0.005,or 0.001% by weight, based on the weight of the esketamine sample, ofthe (R)-enantiomer of ketamine. In yet other embodiments, the esketaminecontains about 0.001 to about 10% by weight, based on the weight of theesketamine sample, of the (R)-enantiomer of ketamine. In still furtherembodiments, the esketamine contains about 0.001 to about 10%, about0.001 to about 5%, about 0.001 to about 1, about 0.001 to about 0.5,about 0.001 to about 0.1, about 0.1 to about 5, about 0.1 to about 1,about 0.1 to about 5, or about 0.5 to about 5% by weight, based on theweight of the esketamine sample, of the (R)-enantiomer of ketamine.

The term “esketamine” may also include other pharmaceutically acceptablesalts thereof, which may readily be selected by those skilled in theart. A “pharmaceutically acceptable salt” is intended to mean a salt ofesketamine that is non-toxic, biologically tolerable, or otherwisebiologically suitable for administration to the subject. See, generally,G. S. Paulekuhn, “Trends in Active Pharmaceutical Ingredient SaltSelection based on Analysis of the Orange Book Database”, J. Med. Chem.,2007, 50:6665-72, S. M. Berge, “Pharmaceutical Salts”, J Pharm Sci.,1977, 66:1-19, and Handbook of Pharmaceutical Salts, Properties,Selection, and Use, Stahl and Wermuth, Eds., Wiley-VCH and VHCA, Zurich,2002. Examples of pharmaceutically acceptable salts are those that arepharmacologically effective and suitable for administration to patientswithout undue toxicity, irritation, or allergic response.

Examples of other pharmaceutically acceptable salts include sulfates,pyrosulfates, bisulfates, sulfites, bisulfites, phosphates,monohydrogen-phosphates, dihydrogenphosphates, metaphosphates,pyrophosphates, bromides (such as hydrobromides), iodides (such ashydroiodides), acetates, propionates, decanoates, caprylates, acrylates,formates, isobutyrates, caproates, heptanoates, propiolates, oxalates,malonates, succinates, suberates, sebacates, fumarates, maleates,butyne-1,4-dioates, hexyne-1,6-dioates, benzoates, chlorobenzoates,methylbenzoates, dinitrobenzoates, hydroxybenzoates, methoxybenzoates,phthalates, sulfonates, xylenesulfonates, phenylacetates,phenylpropionates, phenylbutyrates, citrates, lactates,γ-hydroxybutyrates, glycolates, tartrates, methane-sulfonates,propanesulfonates, naphthalene-1-sulfonates, naphthalene-2-sulfonates,and mandelates. In particular, the salt of esketamine is a hydrochloridesalt.

In certain embodiments of the present invention, the esketamine isadministered intranasally. In certain embodiments of the presentinvention, the esketamine is administered intranasally as itscorresponding hydrochloride salt. In certain embodiments of the presentinvention, the esketamine is administered intranasally as itscorresponding hydrochloride salt in an 16.14% weight/volume solution(equivalent to 14% weight/volume of esketamine base).

In certain embodiments of the present invention, the esketamine isadministered intranasally as a solution comprising 161.4 mg/mL ofesketamine hydrochloride (equivalent to 140 mg/mL of esketamine base),0.12 mg/mL of ethylenediaminetetraacetic acid (EDTA) and 1.5 mg/mLcitric acid, at a pH of 4.5 in water. In certain embodiments of thepresent invention, the esketamine is administered intranasally, whereinthe intranasal delivery administers 100 μL of a solution comprising161.4 mg/mL of esketamine hydrochloride (equivalent to 140 mg/mL ofesketamine base), 0.12 mg/mL of ethylenediaminetetraacetic acid (EDTA)and 1.5 mg/mL citric acid, at a pH of 4.5 in water. In certainembodiments, the esketamine is delivered intranasally using a nasalspray pump, wherein the pump delivers 100 μL of a solution comprising161.4 mg/mL of esketamine hydrochloride (equivalent to 140 mg/mL ofesketamine base), 0.12 mg/mL of ethylenediaminetetraacetic acid (EDTA)and 1.5 mg/mL citric acid, at a pH of 4.5 in water.

In general, a single pump from a nasal spray device may be configured todeliver about 50 μL to about 200 μL of an esketamine solution to anostril of the subject, including about 60 μL, about 70 μL, about 80 μL,about 90 μL, about 100 μL, about 110 μL, about 120 μL, about 130 μL,about 140 μL, about 150 μL, about 160 μL, about 170 μL, about 180 μL,and about 200 μL. Accordingly, two pumps deliver about 100 μL to about400 μL to the subject.

In certain embodiments of the present invention, a patient in need oftreatment with a clinically proven safe and therapeutically effectiveamount of esketamine, is a patient suffering from an episode ofdepression (e.g., major depressive disorder). In certain embodiments ofthe present invention, a patient in need thereof is suffering from anepisode of depression (e.g., major depressive disorder), wherein theepisode of depression (e.g., major depressive disorder) has notresponded to treatment with at least two oral antidepressants (i.e. thepatient has not responded to treatment with at least two oralantidepressants). In other embodiments, a geriatric patient in needthereof is suffering from an episode of depression (e.g., majordepressive disorder), wherein the episode of depression (e.g., majordepressive disorder) has not responded to treatment with two oralantidepressants (i.e. the geriatric patient has not responded totreatment with two oral antidepressants).

In certain embodiments of the present invention, a patient in needthereof is suffering from depression (e.g., major depressive disorder).For example, a patient as measured MADRS with a score of 18 or more oron the CGI scale a score of 4 or more.

As used herein, the term “depression” includes major depressivedisorder, persistent depressive disorder, seasonal affective disorder,postpartum depression, premenstrual dysphoric disorder, situationaldepression, anhedonia, melancholy, mid-life depression, late-lifedepression, depression due to identifiable stressors, treatmentresistant depression, or combinations thereof. In certain embodiments,the depression is major depressive disorder. In other embodiments, themajor depressive disorder is with melancholic features or anxiousdistress. In further embodiments, the depression is treatment-resistantdepression.

As used herein, the term “non-responder” means patients that do notrecover fully on an antidepressant medication (e.g. 25% or less changefrom baseline in total MADRS score).

As used herein, the term “episode of major depressive disorder” means acontinuous period (e.g., about 2 weeks or more) in which a patient hassymptoms of a major depressive disorder sufficient to meet criteria formajor depression as specified in the Diagnostic and statistical Manualof Mental Disorders, 5^(th) Edition: DSM 5.

As used herein, “suicide” is the “act of taking one's own life”. See,http://en.wikipedia.org/wiki/Suicide—cite_note-7. Suicide includesattempted suicide or non-fatal suicidal behavior, which is self-injurywith the desire to end one's life that does not result in death. Suicideattempt is a self-initiated sequence of behaviors by an individual who,at the time of initiation, expected that the set of actions would leadto his or her own death.

As used herein, “suicidal ideation” refers to thoughts about or anunusual preoccupation with suicide, or thoughts of ending one's life ornot wanting to live anymore but not necessarily taking any activeefforts to do so. The range of suicidal ideation varies greatly fromfleeting to chronic and progresses to detailed planning, role playing,and unsuccessful attempts, which may be deliberately constructed to failor be discovered, or may be fully intended to result in death. In someembodiments, a patient is classified as being “suicidal” when thepatient has a mean baseline MADRS total score of about 38 or greater. Inother embodiments, a patient is classified as being suicidal when thepatient has a mean baseline BBSS score of 22 or greater. In furtherembodiments, a patient is classified as being suicidal when the patienthas a score of 6 or greater in the SIBAT clinical global judgement ofsuicide risk. In yet other embodiments, the patient has one or morecombinations of these scores.

As used herein, the terms “co-therapy”, “combination therapy”,“adjunctive treatment”, “adjunctive therapy”, “combined treatment”, and“co-administration” shall mean treatment of a patient in need thereof byadministering esketamine in combination with one or moreantidepressant(s), wherein the esketamine and the antidepressant(s) areadministered by any suitable means. In some embodiments, esketamine isadministered in a regimen with one to five antidepressants. In otherembodiments, esketamine is administered in a regimen with one, two,three, four, or five antidepressants. In other embodiments, esketamineis administered in a regimen with one or two antidepressants. In furtherembodiments, the esketamine is administered in a regimen with theantidepressant currently being administered to the patient. In otherembodiments, the esketamine is administered in a regimen with adifferent antidepressant. In yet further embodiments, the esketamine isadministered in a regimen with an antidepressant not previouslyadministered to the patient. In still other embodiments, the esketamineis administered in a regimen with an antidepressant previouslyadministered to the patient. Where the esketamine and theantidepressant(s) are administered in separate dosage forms, the numberof dosages administered per day for each compound may be the same ordifferent and more typically different. The antidepressant may be dosedas prescribed by the attending physician and/or by its label and theesketamine is dosed as described herein. Typically, a patient is underconcurrent treatment with both an antidepressant and esketamine, whereboth are administered by their prescribed dosing regimens.

The esketamine and the antidepressant(s) may be administered via thesame or different routes of administration. Examples of suitable methodsof administration include, but are not limited to, oral, intravenous(iv), intranasal (in) intramuscular (im), subcutaneous (sc),transdermal, buccal, or rectal. In some embodiments, esketamine isadministered intranasally. As used herein, unless otherwise noted, theterm “antidepressant” shall mean any pharmaceutical agent which can beused to treat depression. Suitable examples include, without limitation,a mono-amine oxidase inhibitor, tricyclic, serotonin reuptake inhibitor,serotonin noradrenergic reuptake inhibitor, noradrenergic and specificserotonergic agent, or atypical antipsychotic. Other examples include,but are not limited to mono-amine oxidase inhibitors such as phenelzine,tranylcypromine, moclobemide, and the like; tricyclics such asimipramine, amitriptyline, desipramine, nortriptyline, doxepin,protriptyline, trimipramine, domipramine, amoxapine, and the like;tetracyclics such as maprotiline, and the like; non-cyclics such asnomifensine, and the like; triazolopyridines such as trazodone, and thelike; serotonin reuptake inhibitors such as fluoxetine, sertraline,paroxetine, citalopram, citalopram, escitalopram, fluvoxamine, and thelike; serotonin receptor antagonists such as nefazadone, and the like;serotonin noradrenergic reuptake inhibitors such as venlafaxine,milnacipran, desvenlafaxine, duloxetine, levomilnacipran and the like;noradrenergic and specific serotonergic agents such as mirtazapine, andthe like; noradrenaline reuptake inhibitors such as reboxetine,edivoxetine and the like; atypical antipsychotics such as bupropion, andthe like; natural products such as Kava-Kava, St. John's Wort, and thelike; dietary supplements such as s-adenosylmethionine, and the like;and neuropeptides such as thyrotropin-releasing hormone and the like;compounds targeting neuropeptide receptors such as neurokinin receptorantagonists and the like; and hormones such as triiodothyronine, and thelike. In some embodiments, the antidepressant is imipramine,amitriptyline, desipramine, nortriptyline, doxepin, protriptyline,trimipramine, maprotiline, amoxapine, trazodone, bupropion, domipramine,fluoxetine, duloxetine, escitalopram, citalopram, sertraline,paroxetine, fluvoxamine, nefazadone, venlafaxine, milnacipran,reboxetine, mirtazapine, phenelzine, tranylcypromine, moclobemide,Kava-Kava, St. John's Wart, s-adenosylmethionine, thyrotropin releasinghormone, a neurokinin receptor antagonist, or triiodothyronine.Preferably, the antidepressant is selected from the group consisting offluoxetine, imipramine, bupropion, venlafaxine and sertraline.

Therapeutically effective amounts/dosage levels and dosage regimens forantidepressants (for example, mono-amine oxidase inhibitors, tricyclics,serotonin reuptake inhibitors, serotonin noradrenergic reuptakeinhibitors, noradrenergic and specific serotonergic agents,noradrenaline reuptake inhibitor, natural products, dietary supplements,neuropeptides, compounds targeting neuropeptide receptors, hormones andother pharmaceutical agents disclosed herein), may be readily determinedby one of ordinary skill in the art. For example, therapeutic dosageamounts and regimens for pharmaceutical agents approved for sale arepublicly available, for example as listed on packaging labels, instandard dosage guidelines, in standard dosage references such as thePhysician's Desk Reference (Medical Economics Company or online athttp://www.pdrel.com) or other sources.

As used herein the term “antipsychotic” includes, but is not limited to:

(a) typical or traditional antipsychotics, such as phenothiazines (e.g.,chlorpromazine, thioridazine, fluphenazine, perphenazine,trifluoperazine, levomepromazin), thioxanthenes (e.g., thiothixene,flupentixol), butyrophenones (e.g., haloperidol), dibenzoxazepines(e.g., loxapine), dihydroindolones (e.g., molindone), substitutedbenzamides (e.g., sulpride, amisulpride), and the like; and

(b) atypical antipsychotics and mood stabilizers, such as paliperidone,clozapine, risperidone, olanzapine, quetiapine, zotepine, ziprasidone,iloperidone, perospirone, blonanserin, sertindole, ORG-5222 (Organon),and the like; and others such as sonepiprazole, aripiprazole,nemonapride, SR-31742 (Sanofi), CX-516 (Cortex), SC-111 (Scotia), NE-100(Taisho), divalproate (mood stabilizer) and the like.

In an embodiment, the “atypical antipsychotic” is selected from thegroup consisting of aripiprazole, quetiapine, olanzapine, risperidoneand paliperidone. In another embodiment, the atypical antipsychotic isselected from the group consisting of aripiprazole, quetiapine,olanzapine and risperidone; preferably, the atypical antipsychotic isselected from the group consisting of aripiprazole, quetiapine andolanzapine.

As used herein, the term “treatment-refractory or treatment-resistantdepression” and the abbreviation “TRD” shall be defined as majordepressive disorder in a patient that does not respond adequately to atleast two different antidepressants, preferably between two and fiveantidepressants, in the current depressive episode. In otherembodiments, TRD is defined as major depressive disorder in a patientthat has not responded to at least two oral antidepressants of adequatedose and duration in the current depressive episode.

One skilled in the art will recognize that the failure to respond to anadequate course of a given antidepressant may be determinedretrospectively or prospectively. In an embodiment, at least one of thefailures to respond to an adequate course of antidepressant isdetermined prospectively. In another embodiment, at least two of thefailures to respond to an adequate course of antidepressant aredetermined prospectively. In another embodiment, at least one of thefailures to respond to an adequate course of antidepressant isdetermined retrospectively. In another embodiment, at least two of thefailures to respond to an adequate course of antidepressant aredetermined retrospectively in a current depressive episode.

The “at least two oral antidepressants” or “at least two different oraldepressants” has been administered to the patient at an adequate dosewhich may be determined by the attending physician. Similarly, theantidepressant has been administered for a suitable duration, asdetermined by the attending physician.

As used herein, unless otherwise noted, the terms “treating”,“treatment” and the like, shall include the management and care of asubject or patient (preferably mammal, more preferably human) for thepurpose of combating a disease, condition, or disorder and includes theadministration of a compound of the present invention to prevent theonset of the symptoms or complications, alleviate the symptoms orcomplications, or eliminate the disease, condition, or disorder.

As used herein, unless otherwise noted, the term “clinically proven”(used independently or to modify the terms “safe” and/or “effective”)shall mean that proof has been proven by a Phase III clinical trial thatare sufficient to meet approval standards of U.S. Food and DrugAdministration or similar study for market authorization by EMEA.Preferably for esketamine studies an adequately sized, randomized,double-blinded controlled study will be used to clinically prove theeffects of esketamine. Most preferably to clinically prove the effectsof esketamine to treat major depressive disorder, e.g., treatmentresistant depression, this would be a randomized, double-blinded,active-controlled study of flexibly dosed intranasal esketamine (28 mg,56 mg or 84 mg±20%) co-administered with a newly or currently initiatedoral antidepressant as compared to a newly or currently initiated oralantidepressant (active comparator) plus intranasal placebo with thepatient's condition assessed by techniques described herein, such as theMADRS, Hamilton, CGI, Beck's Depression Scale, QIDS or PHQ-9, includingassessments from day 1 to day 28, as well as assessments duringsubsequent administration periods as described herein.

As used herein, unless otherwise noted, the term “clinically proveneffective” means the efficacy of treatment has been proven by a PhaseIII clinical trial as statistically significant i.e., the results of theclinical trial are not likely to be due to chance with an alpha levelless than 0.05 or the clinical efficacy results are sufficient to meetapproval standards of U.S. Food and Drug Administration or similar studyfor market authorization by EMEA. For example, esketamine was clinicallyproven effective for the treatment for patients with major depressivedisorder, e.g., treatment resistant depression, when flexibly dosedintranasally in a therapeutically effective dose of from 28 mg, 56 mg or84 mg (±25%) and co-administered with a newly or currently initiatedoral antidepressant in reducing patient MADRS scores by at least about50% relative to the patients measured baseline MADRS score as part of adosing regimen including induction and maintenance phases describedherein, and as specifically set forth in the examples.

As used herein, unless otherwise noted, the term “safe” when referringto a pharmaceutical treatment (therapy) or combination therapy shallmean without undue adverse side effects (such as toxicity, irritation,or allergic response), commensurate with a reasonable benefit/risk ratiowhen used in the manner of this invention.

As used herein, unless otherwise noted, the term “clinically provensafe” means the safety of treatment has been proven by a Phase IIIclinical trial by analysis of the trial data and results establishingthat the treatment is without undue adverse side effects andcommensurate with the statistically significant clinical benefit (e.g.efficacy) sufficient to meet approval standards of U.S. Food and DrugAdministration or similar study for market authorization by EMEA. Forexample, esketamine was clinically proven safe for the treatment forpatients with major depressive disorder, e.g., treatment resistantdepression, when flexibly dosed intranasally in a therapeuticallyeffective dose of from 28 mg, 56 mg or 84 mg (±25%) and co-administeredwith a newly or currently initiated oral antidepressant as part of adosing regimen including induction and maintenance phases describedherein, and as specifically set forth in the examples.

The term “therapeutically effective amount” as used herein, means thatamount of active compound or pharmaceutical agent that elicits thebiological or medicinal response in a tissue system, animal or humanthat is being sought by a researcher, veterinarian, medical doctor orother clinician, which includes alleviation of the symptoms of thedisease or disorder being treated. Desirably, the therapeuticallyeffective amount is a clinically proven safe and clinically proveneffective amount. In some embodiments, the antidepressant is utilized ina therapeutically effective amount as determined by the attendingphysician. In other embodiments, esketamine is utilized in atherapeutically effective amount.

The therapeutically effective amount of esketamine and/or antidepressantmay be administered during the initial phase(s) and/or subsequentphase(s) as described herein. In some embodiments, the therapeuticallyeffective amount of esketamine is about 20 to about 100 mg. In otherembodiments, the therapeutically effective amount of esketamine is about30 to about 90 mg. In further embodiments, the therapeutically effectiveamount of esketamine is about 40 to about 80 mg. In yet otherembodiments, the therapeutically effective amount of esketamine is about14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31,32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49,50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67,68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85,86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100 mg. Infurther embodiments, the therapeutically effective amount is about 28mg, about 56 mg, or about 84 mg. In other embodiments, thetherapeutically effective amount is about 56 mg or about 84 mg. In yetfurther embodiments, the therapeutically effective amount of esketamineis about 28 mg. In other embodiments, the therapeutically effectiveamount of esketamine is about 56 mg. In still further embodiments, thetherapeutically effective amount is of esketamine about 84 mg.

As used herein, unless otherwise noted, the terms “subject” and“patient” refer to an animal, preferably a mammal, most preferably ahuman, who has been the object of treatment, observation or experiment.Preferably, the subject or patient has experienced and/or exhibited atleast one symptom of the disease or disorder to be treated and/orprevented.

In some embodiments, the subject or patient is an adult. As used herein,the term “adult” as used herein refers to a human that is about 18 yearsof age to about 65 years of age.

In other embodiments, the subject or patient is geriatric or elderly. Asused herein, the terms “geriatric” and “elderly” are usedinterchangeably to refer to a human subject of about 65 years of age orolder. Elderly patients between the ages of ≥65 to ≤75 appear to be moreresponsive to treatment than a patient of ≥75.

In further embodiments, the subject or patient is a pediatric subject.As used herein, the term “pediatric” refers to a human subject ofyounger than about 18 years of age.

As used herein, the term “composition” is intended to encompass aproduct comprising the specified ingredients in the specified amounts,as well as any product which results, directly or indirectly, fromcombinations of the specified ingredients in the specified amounts.

As used herein, “stable remission” refers to a patient having a MADRStotal score of 12 or less for at least 3 of the last 4 weeks followingthe patient having achieved a substantially complete response to theesketamine during an induction phase. In certain exemplified embodimentsherein, patients in “stable remission” include those having oneexcursion of a MADRS total score greater than 12 or one missing a MADRSassessment at week 13 or 14 following an induction phase. In otherembodiments, patients in “stable remission” include those having a MADRStotal score at weeks 15 and 16 of 12 or less following an inductionphase.

As used herein, “stable response” refers to a patient having a 50% orgreater reduction in the MADRS total score from baseline (Day 1 ofinduction phase; pre-randomization/prior to the first intranasal dose)in each of the last 2 weeks following the patient having achieved asubstantially complete response to the esketamine during the inductionphase, but does not meet criteria for stable remission.

As noted above, methods of treating depression in a patient aredescribed. The methods include administering esketamine in one, two oroptionally three phases, i.e., initial and subsequent administrationphases. In some embodiments, the phases include an initial inductionphase, an extended induction phase, a maintenance phase, or anycombination thereof. Accordingly, an effective amount of esketamine isadministered in each phase. A physician can assess the patient'scondition to determine the most beneficial initiation/induction andmaintenance doses for the patient from the dosage range andadministration frequencies from those specified herein. The effectiveamount of esketamine may be the same in each phase or may differ.

The methods described herein permit optimizing dosages of esketamine foradministration to a patient having or being predisposed to depression inan “optimization phase”. Optimization may be considered part of themaintenance phase that follows the induction phase. In some embodiments,the methods described herein do not require adjustment of the esketaminedosage. In fact, esketamine may be administered during the phasesdiscussed herein (e.g., induction and maintenance) at the lowest dosingfrequency at which an esketamine response is observed and maintained ina patient. An effective amount of esketamine has been found to be fromabout 28 to about 84 mg.

As used herein, an “Induction phase” or “acute dosing phase” is a periodof time that esketamine is initially administered to the patient. Insome embodiments, the induction phase is sufficiently long as to achievea robust, stable reduction of depressive symptoms. The induction phasemay depend on factors including, without limitation, the particularpatient and/or the patient's sex, age, weight, time of administration,administration frequency and concomitant diseases. The induction phasemay include an initial induction phase and an extended induction phase.The totality of the induction phase (the initial and extended phasestogether) may be a period of about 4 to about 12 weeks, about 4 to about11 weeks, about 4 to about 10 weeks, about 4 to about 9 weeks, about 4to about 8 weeks, about 4 to about 7 weeks, about 4 to about 6 weeks,about 5 to about 12 weeks, about 5 to about 11 weeks, about to about 10weeks, about 5 to about 9 weeks, about 5 to about 8 weeks, about 5 toabout 7 weeks, about 5 to about 6 weeks, about 6 to about 12 weeks,about 6 to about 11 weeks, about 6 to about 10 weeks, about 6 to about 9weeks, about 6 to about 8 weeks, about 7 to about 12 weeks, about 7 toabout 11 weeks, about 7 to about 10 weeks, about 7 to about 9 weeks,about 8 to about 12 weeks, about 8 to about 11 weeks, or about 8 toabout 10 weeks. In some embodiments, the entire induction period isabout 4 to about 8 weeks.

In the initial induction period, a patient is administered atherapeutically effective amount of esketamine at a given frequency ofat least twice a week. In some embodiments, a patient is administered atherapeutically effective amount of esketamine at a given frequency of 3times a week. To the extent that the dosing is 3 times a week, thedosing is on days 1, 3, and 5 of the week±1 day. The initial inductionphase is typically a period of time in which the patient is shown to beresponsive to the treatment, but is not ready to progress to themaintenance phase. At timepoints therein, the patient's response isassessed by one skilled in the art. In some embodiments, the patient'sresponse is assessed daily. In other embodiments, the patient's responseis assessed twice weekly. In further embodiments, the patient's responseis assessed every other day. In yet other embodiments, the patient'sresponse is assessed at the end of the initial induction phase.Typically, the patient's response may be assessed using techniques andtests known to those skilled in the art. In some embodiments, thepatient's MADRS score is determined and used as the determination as towhether the initial induction phase has concluded. The initial inductionphase is desirably long as to achieve a reduction of depressivesymptoms. In some embodiments, the initial induction phase is a periodof about 1 to about 4 weeks. In other embodiments, the induction phaseis a period of up to about 1 week, up to about 2 weeks, up to about 3weeks, or up to about 4 weeks. In further embodiments, the initialinduction period is about 1 to about 3 weeks, about 1 to about 2 weeks,about 2 to about 4 weeks, about 2 to about 3 weeks, about 3 to about 4weeks, 1 week, 2 weeks, 3 weeks, 4 weeks, up to 1 week, up to 2 weeks,up to 3 weeks, or up to 4 weeks. The effective amount of esketamineadministered during the initial induction phase may be determined by theattending physician. In some embodiments, the effective amount ofesketamine administered during the initial induction phase is about 28mg. In some embodiments, the effective amount of esketamine administeredduring the initial induction phase is about 56 mg. In other embodiments,the effective amount of esketamine administered during the initialinduction phase is about 84 mg.

The term “twice weekly” as used herein refers to a frequency that is twotimes in a weekly (7-day) period. For example, “twice weekly” may referherein to the administration of esketamine. “Twice weekly” may alsorefer to a frequency of monitoring a patient in one or more phasesdiscussed herein. In some embodiments, twice weekly refers to afrequency that is day 1 and day 2 of a week. In other embodiments, twiceweekly refers to a frequency that is day 1 and day 3 of a week. Infurther embodiments, twice weekly refers to a frequency that is day 1and day 4 of a week. In still other embodiments, twice weekly refers toa frequency that is day 1 and day 5 of the week. The “day 1” may be anyday of the week, including, Sunday, Monday, Tuesday, Wednesday,Thursday, Friday, or Saturday. Typically, with respect to administrationof esketamine, twice weekly refers to a frequency that is day 1 and day4 of a week. To the extent there is a mis-dose, the dose may be taken assoon as possible thereafter and the prescribed regimen thereaftercontinued.

In some patient populations (such as the elderly) the reduction ofdepressive symptoms during the initial induction phase is insufficient,and an extended induction phase is necessary. In an extended initialinduction phase, continued administration of a therapeutically effectiveamount of esketamine at a given frequency of at least twice a week isperformed. At timepoints therein, the patient's response is againassessed by one skilled in the art. In some embodiments, the patient'sresponse is assessed daily. In other embodiments, the patient's responseis assessed twice weekly. In further embodiments, the patient's responseis assessed every other day. Typically, the patient's response may beassessed using techniques and tests known to those skilled in the art.In some embodiments, the patient's MADRS score is determined and used asthe determination as to whether the extended induction period hasconcluded. The extended induction phase is desirably long as to achievea substantial reduction of depressive symptoms, thus achieving asubstantially complete response to esketamine.

The term “substantially complete response to esketamine” as used hereinrefers to a patient having a reduction of the MADRS score from baselineto at least a 50% improvement from baseline. In some embodiments, asubstantially complete response to esketamine refers to a patient havingeither a MADRS score of at least 50% improvement from baseline or about−20 lower than the patients baseline score. In other embodiments, asubstantially complete response includes a MADRS score of a reduction ofabout −20 or less, −19, or less, −18 or less, −17 or less, −16 or less,−15 or less, −14 or less, −13 or less, −12 or less, −11 or less, or −10or less. In further embodiments, a substantially complete responseresults in a patient having a reduction from MADRS baseline score ofabout −15 to about −20. A substantially complete response to esketaminemay also be obtained if the patient's MADRS scores is reduced by about50% from the MADRS score at the start of the treatment. Such asubstantially complete response may be observed at any point duringesketamine treatment. In some embodiments, the substantially completeresponse is observed when the patient has a reduction of the MADRS totalscore from the baseline 4 hours following treatment. In otherembodiments, the substantially complete response is observed where thepatient has a reduction of the MADRS total score from the baseline 2days following treatment.

The extended induction phase is a period of time that results in thesubstantially complete response to esketamine. In some embodiments,extended induction phase is about 1 to about 8 weeks. In otherembodiments, the extended induction phase is a period of up to about 1week, up to about 2 weeks, up to about 3 weeks, up to about 4 weeks, upto about 5 weeks, up to about 6 weeks, up to about 7 weeks, or up toabout 8 weeks. In further embodiments, the extended induction period isabout 1 to about 8 weeks, about 1 to about 7 weeks, about 1 to about 6weeks, about 1 to about 5 weeks, about 1 to about 4 weeks, about 1 toabout 3 weeks, about 2 to about 8 weeks, about 2 to about 7 weeks, about2 to about 7 weeks, about 2 to about 6 weeks, about 2 to about weeks,about 2 to about 4 weeks, about 3 to about 8 weeks, about 3 to about 7weeks, about 3 to about 6 weeks, about 3 to about 5 weeks, about 4 toabout 8 weeks, about 4 to about 7 weeks, about 4 to about 6 weeks, about5 to about 8 weeks, about 5 to about 7 weeks, about 1 week, about 2weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about7 weeks, or about 8 weeks. The effective amount of esketamineadministered during the extended induction phase may be determined bythe attending physician. In some embodiments, the effective amount ofesketamine administered during the extended induction phase is about 56mg. In other embodiments, the effective amount of esketamineadministered during the extended induction phase is about 84 mg.

The administration may further comprise an optimization/maintenancephase that follows the induction phase and wherein after the patientachieves a substantially complete response to the esketamine during theinduction phase, the esketamine is administered at a frequency of lessthan twice a week during the optimization/maintenance phase. In someembodiments, the frequency of administration during theoptimization/maintenance phase is once every week, once every two weeks,once a month, or a combination thereof.

At any stage during one or more of an induction phase, optimizationphase, or maintenance phase, the patient's response to the treatment maybe assessed using techniques described herein. This assessment may beperformed until the patient is considered by one skilled in the art tohave achieved a suitable response to the treatment regimen. In someembodiments, the induction period may be said to have completed when apatient's MADRS score is reduced by ≥50% from baseline or from about 20to about 13. In other embodiments, the patient's MADRS score may beabout 19, about 18, about 17, about 16, about 15, about 14, or about 13.Patients with MADRS scores ≤12 are considered in remission and if stablefor four weeks should be moved to or maintained in the maintenancephase.

At the end of the induction phase or extended induction phase, thetreating physician should evaluate the patient to optimize the dosingamount and frequency for any subsequent administration phases such asthe “maintenance phase” or “long-term therapy phase”. It is anticipatedthat the intranasal treatment frequency during the subsequentadministration such as the maintenance phase will be reduced from thatin the induction phase or extended induction phase (at least twiceweekly) to once weekly dosing for at least 4 weeks. In some embodiments,the subsequent administration such as the maintenance phase is at leastabout 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8weeks, about 9 week, about 10 weeks, about 11 weeks, about 12 weeks,about 13 weeks, about 17 weeks, about 18 weeks, about 19 weeks, about 20weeks, about 6 months, about 7 months, about 8 months, about 9 months,about 10 months, about 11 months, 1 year, or about 2 years. In someembodiments, the continuing administration of the esketamine during thesubsequent administration phase is for at least six months. In otherembodiments, the continuing administration of the esketamine during thesubsequent administration phase is at least one year. In furtherembodiments, the frequency of administration during the subsequentadministration phase is once every week or once every two weeks, or acombination thereof. In yet other embodiments, the dosing frequency andeffective amount of esketamine during the subsequent administrationphase is the minimum frequency and amount to maintain the stableremission or stable response.

The subsequent administration, such as in a maintenance period, mayinclude longer periods of time depending on the patient's condition. Insome embodiments, those longer periods may be at least about 3 years,about 4 years, about 5 years, about 6 years, about 7 years, about 8years, about 9 years, about 10 years, or more than about 10 years,including indefinitely. For example, for patients diagnosed with TRD,treatment may be indefinite. In other embodiments, the treatmentfrequency is reduced to biweekly. In further embodiments, the treatmentfrequency is reduced to every three weeks. In yet other embodiments, thetreatment frequency is reduced to monthly. The patients will bemaintained on schedule until the patient achieves remission, maintains aresponse, or fails treatment. If the patient achieves remission ormaintains a response with the once a week treatment for at least 4weeks, the frequency of intranasal treatment sessions may be decreasedto a maintenance dose of once every other week based on the severity ofdepressive symptoms and for some patient populations the frequency oftreatment may be reduced to about once every three or four weeks asdiscussed above.

One skilled in the art will recognize that the maintenance phasedescribed herein may continue until further treatment is not requiredand as indicated by, for example, prolonged remission of the depression(including for example, the remission of one or more symptoms associatedwith depression), social and/or occupational functional improvement tonormal or premorbid levels, or other known measures of depression.

An effective amount of esketamine is administered to the patient duringthe maintenance phase. As noted above, the amount of esketamineadministered during the maintenance phase is an amount that elicits thebiological or medicinal response in a tissue system discussed above forthe induction phase. In certain embodiments, the effective amount ofesketamine is the amount which maintains a pharmacodynamic steady stateof esketamine attained in the induction phase. In other embodiments, ifdepressed symptoms begin to worsen with treatment every other week,every three weeks or every four weeks, the dosing of esketamine will beincreased to stabilize the patient. For example if the patient is beingdosed every other week and their symptoms begin to worsen, esketaminecan be administered once per week to maintain response during themaintenance phase. Again, at any time during the maintenance phase thepatient's response maybe reassessed.

For elderly patients, the recommended dose of esketamine is about 28 toabout 84 mg. The initial dose (at the first treatment session) isrecommended to be about 28 mg of esketamine. Based on efficacy andtolerability of the about 28 mg dose, the dose at the next treatmentsession may remain at about 28 mg or be increased to about 56 mg.Depending on efficacy and tolerability of the about 56 mg dose, the doseat subsequent treatment session may remain at about 56 mg or beincreased to about 84 mg, or reduced to about 28 mg. Depending ontolerability of the about 84 mg dose, the dose at subsequent treatmentsessions may remain at about 84 mg or be reduced to about 56 mg.

For hepatically impaired patients, the recommended dose of esketamine isabout 28 to about 56 mg. The initial dose (at the first treatmentsession) is recommended to be about 28 mg of esketamine. Based onefficacy and tolerability of the about 28 mg dose, the dose at the nexttreatment session may remain at about 28 mg or be increased to about 56mg. Physicians should regularly monitor the hepatically impairedpatients for drug tolerability, because esketamine is extensivelymetabolized in the liver.

For the treatment of patients with major depressive disorder withsuicidal ideation and at imminent risk for suicide, dosing is moreaggressive because of the severity of the condition. The methods includeadministering esketamine in one or two phases, i.e., an initialinduction phase, and optionally in certain circumstances a maintenancephase. Due to the imminent risk to the patient's life the initial doseof esketamine is dosed at the highest effective amount of esketaminethat the patient may tolerate twice a week in the induction phase. Insome embodiments, the patient continues on therapy with the existing(i.e. currently initiated) antidepressant agent simultaneously with thebeginning of therapy on esketamine during the induction phase. In otherembodiments, the patient is initiated on a new antidepressant agentsimultaneously with the beginning of therapy on esketamine during theinduction phase. In further embodiments, the patient continues ontherapy with a previously administered antidepressant agentsimultaneously with the beginning of therapy on esketamine during theinduction phase.

The antidepressant should be dosed as labeled for the treatment of MDD,in a manner appropriate for the patient's condition/health. Theinduction phase should be about 4 to about 8 weeks, about 4 to about 7weeks, about 4 to about 6 weeks, most preferably about 4 weeks. At theend of the induction phase the esketamine dosing should cease, if thepatient adequately responds to treatment or is in remission. The patientshould be monitored to ensure that the patient remains stable/or inremission on the antidepressant alone. Should the patient fail tostabilize on the first combination of esketamine and antidepressant orfail treatment on the antidepressant that was initiated with esketamineafter the dosing with esketamine ceases, a second induction phase may bebegun.

In the second induction phase, the patient would be reinitiated onesketamine at the highest tolerable dose and simultaneously with asecond new antidepressant. Alternatively, the patient would bereinitiated on esketamine at the highest tolerable dose andsimultaneously with the same antidepressant that was used during theprevious induction phase. The esketamine being dosed twice a week. Theantidepressant would be dosed as labeled for the treatment of MDD, in amanner appropriate for the patient's condition/health. The secondinduction phase should be about 4 to about 8 weeks, about 4 to about 7weeks, about 4 to about 6 weeks, most preferably about 4 weeks. At theend of the second induction phase, if the patient adequately responds totreatment or is in remission the esketamine dosing should cease and thepatient should be monitored to ensure that the patient remains stable/oris in stable remission on the antidepressant alone. Should the patientfail to stabilize or fail treatment on the antidepressant that wasinitiated with esketamine after the dosing with esketamine ceases, athird induction phase may be begun.

In the third induction phase the patient would be reinitiated onesketamine at the highest tolerable dose and simultaneously with a thirdnew antidepressant. Alternatively, the patient would be reinitiated onesketamine at the highest tolerable dose and simultaneously with thesame antidepressant that was used during the second induction phase. Theesketamine being dosed twice a week. The antidepressant would be dosedas labeled for the treatment of MDD in a manner appropriate for thepatient's condition/health. The third induction phase should be about 4to about 8 weeks, about 4 to about 7 weeks, about 4 to about 6 weeks,most preferably about 4 weeks. At the end of the third induction phasethe patient would proceed to the maintenance phase specified for TRD,since the patient now qualifies as a TRD patient. The methods describedherein permit optimizing dosages of esketamine for administration to apatient having or being predisposed to depression. In some embodiments,the methods described herein do not require adjustment of the esketaminedosage.

In general, the patient may be reinitiated on esketamine at the highesttolerable dose and simultaneously with the same antidepressant that wasused during any previous induction phase, including with anantidepressant in which the patient failed to stabilize or otherwisefailed treatment. For example, in a method for treatingtreatment-resistant depression in a patient wherein the patient has notresponded to at least two oral antidepressants in the current depressiveepisode, the patient may be administered esketamine at least twiceweekly solely with esketamine or along with a first oral antidepressantthat is the same or different than the previously ineffective oralantidepressant in a first induction phase. To the extent the patientfails to achieve a substantially complete response to the esketamine,the patient can be reinitiated at the highest tolerable dose ofesketamine alone or simultaneously with a second oral depressant that isthe same or different than the first oral antidepressant in a secondinduction phase. To the extent the patient achieves a substantiallycomplete response to the esketamine during the second induction phase,the patient can then be administered a therapeutically effective amountof esketamine less than twice weekly during a subsequent maintenancephase.

In the event that one or more (e.g., two) doses of esketamine in any ofthe phases described herein are missed, the next dose is scheduled whenpossible based on the dosing frequency regimen. If more than 2 doses aremissed, per clinical judgement, adjustment of the dose or frequency ofesketamine may be required.

The preferred pharmaceutical composition of the present invention,S-ketamine hydrochloride as the active ingredient is intimately admixedwith a pharmaceutical carrier, preferably water, according toconventional pharmaceutical compounding techniques, which carrier maytake a wide variety of forms depending of the form of preparationdesired for administration. Suitable pharmaceutically acceptablecarriers are well known in the art. Descriptions of some of thesepharmaceutically acceptable carriers may be found in The Handbook ofPharmaceutical Excipients, published by the American PharmaceuticalAssociation and the Pharmaceutical Society of Great Britain.

Methods of formulating pharmaceutical compositions have been describedin numerous publications such as Pharmaceutical Dosage Forms: Tablets,Second Edition, Revised and Expanded, Volumes 1-3, edited by Liebermanet al; Pharmaceutical Dosage Forms: Parenteral Medications, Volumes 1-2,edited by Avis et al; and Pharmaceutical Dosage Forms: Disperse Systems,Volumes 1-2, edited by Lieberman et al; published by Marcel Dekker, Inc.

One suitable aqueous formulation of S-ketamine, comprises water andS-ketamine; wherein the S-ketamine is present in an amount in the rangeof from about 25 mg/mL to about 250 mg/mL, preferably about 55 mg/mL toabout 250 mg/mL or about 100 mg/mL to about 250 mg/mL, or any amount orrange therein, based on the total volume of the pharmaceuticalcomposition. Preferably, the S-ketamine is present in an amount in therange of from about 150 mg/ml to about 200 mg/mL, or any amount or rangetherein. More preferably, the S-ketamine is present in an amount in therange of from about 150 mg/mL to about 175 mg/mL, or any amount or rangetherein. More preferably, the S-Ketamine is present in an amount in therange of from about 160 mg/mL to about 163 mg/mL, for example, in anamount of about 161.4 mg/mL

Another suitable aqueous formulation of S-ketamine comprises water andS-ketamine; wherein the S-ketamine is present in an amount in the rangeof from about eq. 100 mg/mL to about eq. 250 mg/mL, or any amount orrange therein, based on the total volume of the pharmaceuticalcomposition. Preferably, the S-ketamine is present in an amount in therange of from about eq. 125 mg/ml to about eq. 180 mg/mL, or any amountor range therein. More preferably, the S-ketamine is present in anamount in the range of from about eq. 140 mg/mL to about eq. 160 mg/mL,or any amount or range therein, for example, in an amount of about eq.140 mg/mL.

Suitable pharmaceutical compositions for use in the present inventionare preferably an aqueous formulation. As used herein, unless otherwisenoted, the term “aqueous” shall mean that the primary liquid componentof the formulation is water. Preferably, water constitutes greater thanabout 80 wt-% of the liquid component of the pharmaceutical composition,more preferably greater than about 90 wt-%, more preferably greater thanabout 95 wt-%, more preferably about 98 wt-%.

In suitable pharmaceutical compositions for use in the presentinvention, the water content of the composition is within the range of85±14 wt.-%, more preferably 85±12 wt.-%, still more preferably 85±10wt.-%, most preferably 85±7.5 wt-% and in particular 85±5 wt.-%, basedon the total weight of the composition.

In suitable pharmaceutical compositions for use in the presentinvention, preferably the water content of the composition is within therange of 90±14 wt.-%, more preferably 90±12 wt.-%, still more preferably90±10 wt.-%, most preferably 80±7.5 wt-% and in particular 90±5 wt.-%,based on the total weight of the composition.

In another pharmaceutical composition for use in the present invention,the water content of the composition is within the range of 95±4.75wt.-%, more preferably 95±4.5 wt.-%, still more preferably 95±4 wt.-%,yet more preferably 95±3.5 wt.-%, most preferably 95±3 wt.-% and inparticular 95±2.5 wt.-%, based on the total weight of the composition.

In another pharmaceutical composition for use in the present invention,the water content of the composition is within the range of from 75 to99.99 wt.-%, more preferably 80 to 99.98 wt.-%, still more preferably 85to 99.95 wt.-%, yet more preferably 90 to 99.9 wt.-%, most preferably 95to 99.7 wt.-% and in particular 96.5 to 99.5 wt.-%, based on the totalweight of the composition.

In another pharmaceutical composition for use in the present invention,the composition further comprises one or more buffers and/or buffersystems (i.e. conjugate acid-base-pairs).

As used herein, the term “buffer” shall mean any solid or liquidcomposition (preferably an aqueous, liquid composition) which when addedto an aqueous formulation adjusts the pH of said formulation. Oneskilled in the art will recognize that a buffer may adjust the pH of theaqueous formulation in any direction (toward more acidic, more basic ormore neutral pH). Preferably, the buffer is pharmaceutically acceptable.

Suitably examples of buffers which may be used in the aqueousformulations of the present invention include, but are not limited tocitric acid, sodium dihydrogen phosphate, disodium hydrogen phosphate,acetic acid, boric acid, sodium borate, succinic acid, tartaric acid,malic acid, lactic acid, furmaric acid, and the like. Preferably, thebuffer or buffer system is selected from the group consisting of NaOH,citric acid, sodium dihydrogen phosphate and disodium hydrogenphosphate.

In an embodiment, the buffer is selected to adjust the pH of theS-ketamine hydrochloride pharmaceutical compositions of the presentinvention (e.g. the aqueous formulations described herein) into a pH inthe range of from about pH 3.5 to about pH 6.5, or any amount or rangetherein. Preferably, the buffer is selected to adjust the pH of theS-ketamine hydrochloride compositions of the present invention to aboutin the range of from about pH 4.0 to about pH 5.5, or any amount orrange therein, more preferably, in the range of from about pH 4.5 toabout pH 5.0, or any amount or range therein.

Preferably, the concentration of the buffer and buffer system,respectively, preferably NaOH, is adjusted to provide a sufficientbuffer capacity.

In an embodiment, the present invention is directed to a pharmaceuticalcomposition comprising S-ketamine hydrochloride, water, and a buffer orbuffer system, preferably NaOH; wherein the buffer or buffer system ispresent in an amount sufficient to yield a formulation with a pH in therange of from about pH 4.0 to about pH 6.0, or any amount or rangetherein.

Optionally the pharmaceutical compositions of the present invention maycontain a preservative.

As used herein, unless otherwise noted, the terms “antimicrobialpreservative” and “preservative” preferably refer to any substance thatis usually added to pharmaceutical compositions in order to preservethem against microbial degradation or microbial growth. In this regard,microbial growth typically plays an essential role, i.e. thepreservative serves the main purpose of avoiding microbialcontamination. As a side aspect, it may also be desirable to avoid anyeffect of the microbes on the active ingredients and excipients,respectively, i.e. to avoid microbial degradation.

Representative examples of preservatives include, but are not limitedto, benzalkonium chloride, benzethonium chloride, benzoic acid, sodiumbenzoate, benzyl alcohol, bronopol, cetrimide, cetylpyridinium chloride,chlorhexidine, chlorbutanol, chlorocresol, chloroxylenol, cresol, ethylalcohol, glycerin, hexetidine, imidurea, phenol, phenoxyethanol,phenylethyl alcohol, phenylmercuric nitrate, propylene glycol, sodiumpropionate, thimerosal, methyl paraben, ethyl paraben, propyl paraben,butyl paraben, isobutyl paraben, benzyl paraben, sorbic acid, andpotassium sorbate.

The complete absence of preservatives in the pharmaceutical compositionsused in the present invention is preferred when the content ofS-ketamine hydrochloride is sufficiently high so that due to itspreservative property the desired shelf life or in use stability can beachieved by the presence of the drug itself. Preferably, under thesecircumstances the concentration of S-ketamine hydrochloride is at leasteq. 120 mg/mL, preferably in the range of from about eq. 120 mg/mL toabout eq. 175 mg/ml, or any amount or range therein, more preferably inan amount in the range of from about eq. 125 mg/mL to about eq. 150mg/mL, or any amount or range therein, for example at about eq. 126mg/mL or at about eq. 140 mg/mL.

As used herein, the terms “penetration agent”, “penetration enhancer”,and “penetrant” refer to any substance that increases or facilitatesabsorption and/or bioavailability of the active ingredient (e.g.S-ketamine hydrochloride) of a pharmaceutical composition. Preferably,the penetration agents increases or facilitates absorption and/orbioavailability of the active ingredient (e.g. S-ketamine hydrochloride)of a pharmaceutical composition, following nasal administration (i.e.increases or facilitates absorption and/or bioavailability of the activeingredient through the mucosal membrane).

Suitable examples include, but are not limited to tetradecyl maltoside,sodium glycocholate, tauroursodeoxycholic acid (TUDCA), lecithines, andthe like; and chitosan (and salts), and surface active ingredients suchas benzalkonium chloride, sodium dodecyl sulfate, sodium docusate,polysorbates, laureth-9, oxtoxynol, sodium deoxycholate, polyarginine,and the like. Preferably, the penetration agent is tauroursodeoxycholicacid (TUDCA).

The penetration agent may work via any mechanism, including for exampleby increasing the membrane fluidity, creating transient hydrophilicpores in the epithelial cells, decreasing the viscosity of the mucuslayer or opening up tight junctions. Some penetration agents (forexample bile salts and fusidic acid derivatives) may also inhibit theenzymatic activity in the membrane, thereby improving bioavailability ofthe active ingredient.

Preferably, the penetration agent is selected to meet one or more, morepreferably all, of the following general requirements:

-   -   (a) It is effective at increasing absorption (preferably nasal        absorption) of the active ingredient, preferably in a temporary        and/or reversible manner;    -   (b) It is pharmacologically inert;    -   (c) It is non-allergic, non-toxic and/or non-irritating;    -   (d) It is highly potent (effective in small amounts);    -   (e) It is compatible with the other components of the        pharmaceutical composition;    -   (f) It is odorless, colorless and/or tasteless;    -   (g) It is accepted by regulatory agencies; and    -   (h) It is inexpensive and available in high purity.

In one embodiment of the present invention, the penetration agent isselected to increase penetration (absorption and/or bioavailability ofthe S-ketamine hydrochloride) without nasal irritation. In anotherembodiment of the present invention, the penetration agent is selectedto improve absorption and/or bioavailability of the S-ketaminehydrochloride; and further selected to enhance uniform dosing efficacy.

In an embodiment, the present invention is directed to a pharmaceuticalcomposition comprising S-ketamine and water; herein the pharmaceuticalcomposition does not contain an antimicrobial preservative; and whereinthe pharmaceutical compositions further contains a penetration enhancer,preferably TUDCA.

In another embodiment, the present invention is directed to apharmaceutical composition comprising S-ketamine and water; herein thepharmaceutical composition does not contain an antimicrobialpreservative; and wherein the pharmaceutical compositions furthercontains tauroursodeoxycholic acid (TUDCA); wherein the TUDCA is presentin a concentration in the range of from about 1.0 mg/mL to about 25.0mg/mL, or any amount or range therein, preferably in a concentration inthe range of from about 2.5 mg/mL to about 15 mg/mL, or any amount orrange therein, preferably in a concentration in the range of from about5 mg/mL to about 10 mg/mL, or any amount or range therein. In anotherembodiment, the present invention is directed to pharmaceuticalcomposition wherein the TUDCA is present at a concentration of about 5mg/mL. In another embodiment, the present invention is directed topharmaceutical composition wherein the TUDCA is present at aconcentration of about 10 mg/mL.

The pharmaceutical compositions for use in the present invention mayfurther contain one or more additional excipients for example, wettingagents, surfactant components, solubilizing agents, thickening agents,colorant agents, antioxidant components, and the like.

Examples of a suitable antioxidant component, if used, include, but arenot limited to one or more of the following: sulfites; ascorbic acid;ascorbates, such as sodium ascorbate, calcium ascorbate, or potassiumascorbate; ascorbyl palmitate; fumaric acid; ethylene diaminetetraacetic acid (EDTA) or its sodium or calcium salts; tocopherol;gallates, such as propyl gallate, octyl gallate, or dodecyl gallate;vitamin E; and mixtures thereof. The antioxidant component provides longterm stability to the liquid compositions. Addition of the antioxidantcomponent can help enhance and ensure the stability of the compositionsand renders the compositions stable even after six months at 40° C. Asuitable amount of the antioxidant component, if present, is about 0.01wt.-% to about 3 wt.-%, preferably about 0.05 wt.-% to about 2 wt.-%, ofthe total weight of the composition.

Solubilizing and emulsifying agents can be included to facilitate moreuniform dispersion of the active ingredient or other excipient that isnot generally soluble in the liquid carrier. Examples of a suitableemulsifying agent, if used, include, but are not limited to, forexample, gelatin, cholesterol, acacia, tragacanth, pectin, methylcellulose, carbomer, and mixtures thereof. Examples of a suitablesolubilizing agent include polyethylene glycol, glycerin, D-mannitol,trehalose, benzyl benzoate, ethanol, trisaminomethane, cholesterol,triethanolamine, sodium carbonate, sodium citrate, sodium salicylate,sodium acetate, and mixtures thereof.

Preferably, the solubilizing agent includes glycerin. The solubilizingor emulsifying agent is/are generally present in an amount sufficient todissolve or disperse the active ingredient, i.e. S-ketamine, in thecarrier. Typical amounts when a solubilizing or an emulsifier areincluded are from about 1 wt.-% to about 80 wt.-%, preferably about 20wt.-% to about 65 wt.-%, and more preferably about 25 wt.-% to about 55wt.-%, of the total weight of the composition.

A suitable isotonizing agent, if used, includes sodium chloride,glycerin, D-mannitol, D-sorbitol, glucose, and mixtures thereof. Asuitable amount of the isotonizing agent, when included, is typicallyabout 0.01 wt.-% to about 15 wt.-%, more preferably about 0.3 wt.-% toabout 4 wt.-%, and more preferably about 0.5 wt.-% to about 3 wt.-%, ofthe total weight of the composition.

A suspending agent or viscosity increasing agent can be added to thepharmaceutical compositions of the present invention, to for example,increase the residence time in the nose. Suitably examples include, butare not limited to, hydroxypropyl methylcellulose, sodium carmellose,microcrystalline cellulose, carbomer, pectin, sodium alginate, chitosansalts, gellan gum, poloxamer, polyvinyl pyrrolidone, xanthan gum, andthe like.

Advantageously, esketamine may be administered in a single daily dose,or the total daily dosage may be administered in divided doses of two,three or four times daily, preferably two times daily. Typically,divided doses should be made closer in time. In some embodiments,divided doses are administered about within 20 minutes, about 15minutes, about 10 minutes, about 5 minutes, about 4 minutes, about 3minutes, about 2 minutes, about 1 minute, or less of each other.Additionally, in a flexible dosing regimen a patient could be doseddaily, twice a week, once a week, once every other week or once monthly.For example, one dose of the esketamine is administered on day 1 andanother dose of the esketamine is administered on day 2, or one dose ofthe esketamine is administered on day 1 and another dose of theesketamine is administered on day 3, or one dose of the esketamine isadministered on day 1 and another dose of the esketamine is administeredon day 4, or one dose of the esketamine is administered on day 1 andanother dose of the esketamine is administered on day 5. Furthermore,esketamine is preferably administered in intranasal form via topical useof suitable intranasal vehicles, such as a nasal spray pump.

As described, the methods of administering esketamine to a patientresult in a pharmacokinetic profile that achieves a maximum plasmaconcentration (C_(max)) of esketamine of about 45 to about 165 ng/mL.One skilled in the art would understand that any of the ranges orindividual C_(max) values may vary by ±30%. In some embodiments, theC_(max) is about 45, about 50, about 55, about 60, about 65, about 70,about 75, about 80, about 85, about 90, about 95, about 100, about 105,about 110, about 115, about 120, about 125, about 130, about 135, about140, about 145, about 150, about 155, about 160, or about 165 ng/mL. Inother embodiments, the C_(max) is about 50 to about 150, about 50 toabout 125, about 50 to about 100, about 50 to about 75, about 75 toabout 150, about 75 to about 125, or about 75 to about 100 ng/mL. Infurther embodiments, the C_(max) is about to about 75, about 50 to about70, about 55 to about 65, about 45 to about 70, about 45 to about 65,about 45 to about 60, about 45 to about 55, about 55 to about 75, orabout 60 to about 70 ng/mL, when about 28 mg of esketamine isadministered. In yet other embodiments, the C_(max) is about 65 to about120, about 70 to about 120, about 70 to about 110, about 70 to about100, about 70 to about 90, about 70 to about 80, about 80 to about 120,about 80 to about 110, about 80 to about 90, about 90 to about 120, orabout 90 to about 110 ng/mL, when about 56 mg of esketamine isadministered. In still further embodiments, the C_(max) is about 90 toabout 165, about 95 to about 165, about 95 to about 155, about 95 toabout 145, about 95 to about 135, about 95 to about 125, about 95 toabout 115, about 105 to about 165, about 105 to about 155, about 105 toabout 145, about 105 to about 135, about 105 to about 125, about 105 toabout 115, about 115 to about 165, about 115 to about 155, about 115 toabout 145, about 115 to about 135, about 115 to about 125, about 125 toabout 165, about 125 to about 155, about 125 to about 145, about 125 toabout 135, about 135 to about 165, about 135 to about 155, about 135 toabout 145, or about 145 to about 165 ng/mL, when about 84 mg ofesketamine is administered.

Similarly, the methods of administering esketamine to a patient resultsin a pharmacokinetic profile that achieves an area under the plasmaconcentration-time curve from time 0 to time of last quantifiableconcentration (AUC_(last)) of about 125 to about 490 ng*h/mL. The term“AUC_(last)” as used herein refers to the area under the plasmaconcentration-time curve from time zero to time of last measurableconcentration. “Time zero” in a general context refers to the startpoint of the intended dose. For example, in Example 1 regardingintranasal administration, time 0 is defined as the time ofadministration of the first intranasal spray to one nostril from thefirst intranasal device. To the extent the intended dose requiresadministration of two oral tablets, time 0 is the time of administrationof the first tablet. One skilled in the art would understand that any ofthe ranges or individual AUC_(last) values may vary by ±30%. In someembodiments, the AUC_(last) is about 125, about 130, about 135, about140, about 145, about 150, about 160, about 170, about 180, about 190,about 200, about 210, about 220, about 230, about 240, about 250, about260, about 270, about 280, about 290, about 300, about 310, about 320,about 330, about 340, about 350, about 360, about 370, about 380, about390, about 400, about 410, about 420, about 430, about 440, about 450,about 460, about 470, about 480, or about 490 ng*h/mL. In otherembodiments, the AUC_(last) is about 150 to about 450, about 200 toabout 400, about 250 to about 350, about 150 to about 350, or about 200to about 300 ng*h/mL. In further embodiments, the AUC_(last) is about125 to about 185, about 130 to about 180, about 135 to about 175, about140 to about 170, about 145 to about 165, or about 150 to about 160ng*h/mL, when about 28 mg of esketamine is administered. In yet otherembodiments, the AUC_(last) is about 210 to about 320, about 220 toabout 310, about 230 to about 300, about 240 to about 290, about 250 toabout 280, or about 260 to about 270 ng*h/mL, when about 56 mg ofesketamine is administered. In still further embodiments, the AUC_(last)is about 305 to about 490, about 310 to about 480, about 320 to about470, about 330 to about 460, about 340 to about 450, about 350 to about450, about 360 to about 440, about 370 to about 430, about 380, about420, or about 390 to about 410 ng*h/mL, when about 84 mg of esketamineis administered.

The methods of administering esketamine may also result in apharmacokinetic profile that achieves combinations of the C_(max) andAUC_(last) individual values and ranges described above.

A representative nasal spray device is disclosed in U.S. Pat. No.6,321,942, incorporated by reference herein. For example, a disposableatomizer for discharging successive partial discharge amounts as a spraymay be utilized to carry out the methods discloses herein. Typically,such devices allow a medicament to be sprayed into both nostrils of apatient in two successive strokes. The device may be ready-to-usewherein the medicament is discharged from a medium container. The deviceis typically able to separate a first discharge stroke from a seconddischarge stroke to prevent complete emptying of the medium container ina single motion. The device may take the form of a double-strokedisposable pump, which is disposed of after a single use and enablesindividual partial discharges with high dosing precision andreliability.

In one embodiment, the nasal spray device is a single-use device thatdelivers a total of 28 mg of esketamine in two sprays, one spray pernostril. The device may be operated by the patient under the supervisionof a healthcare professional. With respect to dosage amounts, one devicemay be used for a 28 mg dose, two devices for a 56 mg dose, or threedevices for an 84 mg dose. It is also preferable to have a 5-minuteinterval between the use of each device. As described in Example 1, time0 is defined as the time of administration of the first intranasal sprayto one nostril from the first intranasal device.

As depicted in FIGS. 83A to 83E, instructions for use will accompany aesketamine nasal spray drug product according to the present disclosure.In one aspect, the instructions for use are on the drug product label ofan approved drug product. In certain aspects, the drug product comprisesone or more intranasal spray devices, with the one or more devicescomprising esketamine. The one or more devices is configured toadminister the esketamine in two or more sprays, preferably two sprays,1 spray per nostril of the patient.

An exemplary device is illustrated in FIG. 83A and comprises a tip, anose rest, an indicator, a finger rest, and a plunger. The indicatorindicates if the device is full, how many sprays have been administered,and/or whether or not the device is empty. The indication may beaccomplished, for example, by using colored dots, where two colored dotsindicate a full device, one colored dot indicates one spray has beenadministered, and no colored dots signifies an empty device.

In certain aspects, the device is intended for administration by thepatient under the supervision of a health care professional (HCP). Thehealth care professional may be, for example, a doctor, psychiatrist, ornurse that preferably has completed an education and training programfor informing healthcare professionals about the appropriate use ofesketamine according to United States Prescribing Information (USPI).This may include an educational program with clinical educators,instructional materials, videos and web-based education.

In an exemplary use embodiment, a first step includes an instruction forthe patient to blow their nose before using a first device. A device maybe configured to administer from about 28 to about 84 mg of esketamine.In preferred embodiments, each device contains about 28 mg ofesketamine, with additional devices utilized if administering 56 mg or84 mg of esketamine. For example, three devices may be used toadminister 84 mg of esketamine. Before use, the device should not beprimed as this will result in loss of medication. At the start of use,the patient's head is preferably reclined at about 45 degrees to keepthe medication inside the nose.

Typically, the tip of the device is inserted into a first nostril, andthe patient should dose the opposite nostril and breathe through thenose while activating the plunger to release the medication. The tip ofthe device is then inserted into the second nostril to deliver theremaining amount of esketamine. At this point, the HCP may take thedevice from the patient and confirm that the device is empty. If not,the patient should spray again into the second nostril.

Before a next administration from a second device, the patient shouldrest, preferably in a reclined position, for about 5 minutes beforeadministering additional esketamine from a second device. The steps maybe repeated for the second device. If a third device is needed, thepatient should again wait about 5 minutes following the second spray tothe second nostril before administering additional esketamine to thefirst nostril from a third device. Having the patient wait about 5minutes after each device allows the medication to absorb. A used devicemay be disposed in accordance with local requirements.

In certain aspects, methods of selling a drug product comprisingesketamine are also provided. The terms “sale” or “selling” as usedherein refers to transferring a drug product, e.g., a pharmaceuticalcomposition or a dosage form, from a seller to a buyer. In someembodiments, a drug product label for a reference listed drug for thedrug product includes instructions for treating depression, includingtreatment-resistant depression. The methods also include offering forsale a drug product comprising esketamine. The term “offering for sale,”as used herein, refers to the proposal of a sale by a seller to a buyerfor a drug product, e.g., a pharmaceutical composition or a dosage form.These methods comprise offering the drug product for sale.

The term “drug product” is product that contains an activepharmaceutical ingredient that has been approved for marketing by agovernmental authority, e.g., the Food and Drug Administration or thesimilar authority in other countries.

Similarly, “label” or “drug product label” refers to informationprovided to a patient which provides relevant information regarding thedrug product. Such information includes, without limitation, one or moreof the description of the drug, clinical pharmacology, indications (usesfor the drug product), contraindication (who should not take the drugproduct), warnings, precautions, adverse events (side effects), drugabuse and dependence, dosage and administration, use in pregnancy, usein nursing mothers, use in children and older patients, how the drug issupplied, safety information for the patient, or any combinationthereof. In certain embodiments, the label or drug product labelprovides an instruction for use in a patient with treatment-resistantdepression. In other embodiments, the drug product label comprises datadirected to the reduction of depressive symptoms relative to a placeboand/or standard of care. In further embodiments, the label or drugproduct label identifies esketamine as a regulatory approved chemicalentity. In still other embodiments, the label provides instructions foruse in a patient with depression, including treatment-resistantdepression.

The term “reference listed drug” or “RLD” as used herein refers to adrug product to which new generic versions are compared to show thatthey are bioequivalent. It is also a medicinal product that has beengranted marketing authorization by a member state of the European Unionor by the Commission on the basis of a completed dossier, i.e., with thesubmission of quality, pre-clinical and clinical data in accordance withArticles 8(3), 10a, 10b or 10c of Directive 2001/83/EC and to which theapplication for marketing authorization for a generic/hybrid medicinalproduct refers, by demonstration of bioequivalence, usually through thesubmission of the appropriate bioavailability studies.

In the United States, a company seeking approval to market a genericequivalent must refer to the RLD in its Abbreviated New Drug Application(ANDA). For example, an ANDA applicant relies on the FDA's finding thata previously approved drug product, i.e., the RLD, is safe andeffective, and must demonstrate, among other things, that the genericdrug product is the same as the RLD in certain ways. Specifically, withlimited exceptions, a drug product for which an ANDA is submitted musthave, among other things, the same active ingredient(s), conditions ofuse, route of administration, dosage form, strength, and (with certainpermissible differences) labeling as the RLD. The RLD is the listed drugto which the ANDA applicant must show its ANDA drug product is the samewith respect to active ingredient(s), dosage form, route ofadministration, strength, labeling and conditions of use, among othercharacteristics. In the electronic Orange Book, there is a column forRLDs and a column for reference standards. In the printed version of theOrange Book, the RLDs and reference standards are identified by specificsymbol.

A reference standard is the drug product selected by FDA that anapplicant seeking approval of an ANDA must use in conducting an in vivobioequivalence study required for approval. FDA generally selects asingle reference standard that ANDA applicants must use in in vivobioequivalence testing. Ordinarily, FDA will select the reference listeddrug as the reference standard. However, in some instances (e.g., wherethe reference listed drug has been withdrawn from sale and FDA hasdetermined it was not withdrawn for reasons of safety or effectiveness,and FDA selects an ANDA as the reference standard), the reference listeddrug and the reference standard may be different.

FDA identifies reference listed drugs in the Prescription Drug Product,OTC Drug Product, and Discontinued Drug Product Lists. Listed drugsidentified as reference listed drugs represent drug products upon whichan applicant can rely in seeking approval of an ANDA. FDA intends toupdate periodically the reference listed drugs identified in thePrescription Drug Product, OTC Drug Product, and Discontinued DrugProduct Lists, as appropriate.

FDA also identifies reference standards in the Prescription Drug Productand OTC Drug Product Lists. Listed drugs identified as referencestandards represent the FDA's best judgment at this time as to theappropriate comparator for purposes of conducting any in vivobioequivalence studies required for approval.

In some instances when FDA has not designated a listed drug as areference listed drug, such listed drug may be shielded from genericcompetition. If FDA has not designated a reference listed drug for adrug product the applicant intends to duplicate, the potential applicantmay ask FDA to designate a reference listed drug for that drug product.

FDA may, on its own initiative, select a new reference standard whendoing so will help to ensure that applications for generic drugs may besubmitted and evaluated, e.g., in the event that the listed drugcurrently selected as the reference standard has been withdrawn fromsale for other than safety and efficacy reasons.

In Europe, Applicants identify in the application form for itsgeneric/hybrid medicinal product, which is the same as an ANDA orsupplemental NDA (sNDA) drug product, the reference medicinal product(product name, strength, pharmaceutical form, marketing authorizationholder (MAH, first authorization, Member State/Community), which issynonymous with a RLD, as follows:

1. The medicinal product that is or has been authorized in the EuropeanEconomic Area (EEA), used as the basis for demonstrating that the dataprotection period defined in the European pharmaceutical legislation hasexpired. This reference medicinal product, identified for the purpose ofcalculating expiry of the period of data protection, may be for adifferent strength, pharmaceutical form, administration route orpresentation than the generic/hybrid medicinal product.

2. The medicinal product, the dossier of which is cross-referred to inthe generic/hybrid application (product name, strength, pharmaceuticalform, MAH, marketing authorization number). This reference medicinalproduct may have been authorized through separate procedures and under adifferent name than the reference medicinal product identified for thepurpose of calculating expiry of the period of data protection. Theproduct information of this reference medicinal product will, inprinciple, serve as the basis for the product information claimed forthe generic/hybrid medicinal product.

3. The medicinal product (product name, strength, pharmaceutical form,MAH, Member State of source) used for the bioequivalence study(ies)(where applicable).

The different abbreviated approval pathways for drug products under theFood, Drug, and Cosmetics (FD&C) Act are the abbreviated approvalpathways described in sections 505(j) and 505(b)(2) of the FD&C Act (21U.S.C. 355(j) and 21 U.S.C. 23 355(b)(2), respectively).

According to the FDA (“Determining Whether to Submit an ANDA or a505(b)(2) Application Guidance for Industry,” U.S. Department of Healthand Human Services, October 2017, pp. 1-14, the contents of which isincorporated herein by reference), NDAs and ANDAs can be divided intothe following four categories:

(1) A “stand-alone NDA” is an application submitted under section505(b)(1) and approved under section 505(c) of the FD&C Act thatcontains full reports of investigations of safety and effectiveness thatwere conducted by or for the applicant or for which the applicant has aright of reference or use.

(2) A section 505(b)(2) application is an NDA submitted under section505(b)(1) and approved under section 505(c) of the FD&C Act thatcontains full reports of investigations of safety and effectiveness,where at least some of the information required for approval comes fromstudies not conducted by or for the applicant and for which theapplicant has not obtained a right of reference or use.

(3) An ANDA is an application for a duplicate of a previously approveddrug product that was submitted and approved under section 505(j) of theFD&C Act. An ANDA relies on the FDA's finding that the previouslyapproved drug product, i.e., the reference listed drug (RLD), is safeand effective. An ANDA generally must contain information to show thatthe generic product (a) is the same as the RLD with respect to theactive ingredient(s), conditions of use, route of administration, dosageform, strength, and labeling (with certain permissible differences) and(b) is bioequivalent to the RLD. An ANDA may not be submitted if studiesare necessary to establish the safety and effectiveness of the product.

(4) A petitioned ANDA is a type of ANDA for a drug product that differsfrom the RLD in its dosage form, route of administration, strength, oractive ingredient (in a product with more than one active ingredient)and for which FDA has determined, in response to a petition submittedunder section 505(j)(2)(C) of the FD&C Act (suitability petition), thatstudies are not necessary to establish the safety and effectiveness ofthe drug product.

A scientific premise underlying the Hatch-Waxman Act is that a drugproduct approved in an ANDA under section 505(j) of the FD&C Act ispresumed to be therapeutically equivalent to its RLD. Productsclassified as therapeutically equivalent can be substituted with thefull expectation that the substituted product will produce the sameclinical effect and safety profile as the prescribed product whenadministered to patients under the conditions specified in the labeling.In contrast to an ANDA, a section 505(b)(2) application allows greaterflexibility as to the characteristics of the product. A section505(b)(2) application will not necessarily be rated therapeuticallyequivalent to the listed drug it references upon approval.

The term “therapeutically equivalent to a reference listed drug” ismeans that the drug product is a generic equivalent, i.e.,pharmaceutical equivalents, of the reference listed drug product and, assuch, is rated an AB therapeutic equivalent to the reference listed drugproduct by the FDA whereby actual or potential bioequivalence problemshave been resolved with adequate in vivo and/or in vitro evidencesupporting bioequivalence.

“Pharmaceutical equivalents” means drug products in identical dosageforms and route(s) of administration that contain identical amounts ofthe identical active drug ingredient as the reference listed drug.

FDA classifies as therapeutically equivalent those products that meetthe following general criteria: (1) they are approved as safe andeffective; (2) they are pharmaceutical equivalents in that they (a)contain identical amounts of the same active drug ingredient in the samedosage form and route of administration, and (b) meet compendial orother applicable standards of strength, quality, purity, and identity;(3) they are bioequivalent in that (a) they do not present a known orpotential bioequivalence problem, and they meet an acceptable in vitrostandard, or (b) if they do present such a known or potential problem,they are shown to meet an appropriate bioequivalence standard; (4) theyare adequately labeled; and (5) they are manufactured in compliance withCurrent Good Manufacturing Practice regulations

The term “bioequivalent” or “bioequivalence” is the absence of asignificant difference in the rate and extent to which the activeingredient or active moiety in pharmaceutical equivalents orpharmaceutical alternatives becomes available at the site of drug actionwhen administered at the same molar dose under similar conditions in anappropriately designed study. Section 505 (j)(8)(B) of the FD&C Actdescribes one set of conditions under which a test and reference listeddrug shall be considered bioequivalent:

the rate and extent of absorption of the [test] drug do not show asignificant difference from the rate and extent of absorption of the[reference] drug when administered at the same molar dose of thetherapeutic ingredient under similar experimental conditions in either asingle dose or multiple doses; or

the extent of absorption of the [test] drug does not show a significantdifference from the extent of absorption of the [reference] drug whenadministered at the same molar dose of the therapeutic ingredient undersimilar experimental conditions in either a single dose or multipledoses and the difference from the [reference] drug in the rate ofabsorption of the drug is intentional, is reflected in its labeling, isnot essential to the attainment of effective body drug concentrations onchronic use, and is considered medically insignificant for the drug.

Where these above methods are not applicable (e.g., for drug productsthat are not intended to be absorbed into the bloodstream), otherscientifically valid in vivo or in vitro test methods to demonstratebioequivalence may be appropriate.

For example, bioequivalence may sometimes be demonstrated using an invitro bioequivalence standard, especially when such an in vitro test hasbeen correlated with human in vivo bioavailability data. In othersituations, bioequivalence may sometimes be demonstrated throughcomparative clinical trials or pharmacodynamic studies.

The methods may also comprise, consist of, or consist essentially ofplacing esketamine into the stream of commerce. In certain embodiments,the esketamine drug product includes a package insert that containsinstructions for safely and effectively treating depression, includingtreatment-resistant depression, using esketamine. In still furtheraspects, described herein are methods of offering for sale esketaminecomprising, consisting of, or consisting essentially of offering anesketamine drug product into the stream of commerce. In certainembodiments, the esketamine drug product includes a package insert thatcontains instructions for safely and effectively treating depression,including treatment-resistant depression, using esketamine.

Aspects of the Disclosure

The present disclosure pertains to and includes at least the followingaspects.

1. A method for treating major depressive disorder comprisingintranasally administering to a patient in need thereof, a clinicallyproven safe and clinically proven effective therapeutically effectiveamount of esketamine;

wherein the patient in need thereof is a human patient having a majordepressive episode and wherein the patient has not responded to at leasttwo oral antidepressants in the current depressive episode.

2. A method of treating major depressive disorder comprisingadministering esketamine to a patient in need thereof;

wherein the patient in need thereof is having a major depressive episodeand wherein the patient has not responded to at least two oralantidepressants in the current depressive episode;

wherein the esketamine is administered intranasally;

and wherein the therapeutically effective amount of esketamineadministered to the patient is clinically proven safe and effective.

3. A method for treating major depressive disorder in a human patientcomprising the steps of:

(a) diagnosing said human patient by measuring said human patient'sbaseline MADRS score;

(b) intranasally administering to said human patient a therapeuticallyeffective amount of esketamine that is clinically proven safe andeffective;

wherein the therapeutically effective amount improves said MADRS scoreof at least 50% relative to the measured baseline MADRS score;

and wherein the esketamine is administered at pre-determined intervals;and

(c) re-evaluating said human patient at regular intervals following step(b) to determine relative effectiveness;

wherein the re-evaluation comprises measurement of said human patient'sMADRS score.

4. The method of aspects 1, 2 or 3 wherein the major depressive disorderis treatment refractory depression or treatment resistant depression.

5. The method of aspects 1, 2, 3 or 4 wherein a therapeuticallyeffective amount of at least one antidepressant is co-administered withesketamine.

6. The method of aspect 5, wherein the combination therapy comprisesesketamine and one to two antidepressants.

7. The method of aspect 5, wherein each antidepressant is independentlyselected from the group consisting of imipramine, amitriptyline,desipramine, nortriptyline, doxepin, protriptyline, trimipramine,maprotiline, amoxapine, trazodone, bupropion, clomipramine, fluoxetine,duloxetine, escitalopram, citalopram, sertraline, paroxetine,fluvoxamine, nefazadone, venlafaxine, milnacipran, reboxetine,mirtazapine, phenelzine, tranylcypromine, moclobemide, Kava-Kava, St.John's Wart, s-adenosylmethionine, thyrotropin releasing hormone,neurokinin receptor antagonists and triiodothyronine.

8. The method of aspect 5, wherein each antidepressant is independentlyselected from the group consisting of mono-amine oxidase inhibitors,tricyclics, serotonin reuptake inhibitors, serotonin noradrenergicreuptake inhibitors; noradrenergic and specific serotonergic agents andatypical antidepressants.

9. The method of aspect 5, wherein each antidepressant is independentlyselected from the group consisting of phenelzine, tranylcypromine,moclobemide, imipramine, amitriptyline, desipramine, nortriptyline,doxepin, protriptyline, trimipramine, clomipramine, amoxapine,fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine,venlafaxine, milnacipran, mirtazapine and bupropion.

10. The method of aspect 5, wherein the combination therapy comprisesesketamine and one to two antidepressants independently selected fromthe group consisting of fluoxetine, imipramine, bupropion, venlafaxineand sertraline.

11. The method of aspect 5, wherein the combination therapy comprisingesketamine and at least one antidepressant further comprises an atypicalantidepressant.

12. The method of aspect 11, wherein the atypical antidepressant isselected from the group consisting of aripiprazole, quetiapine,olanzapine, risperidone and paliperidone.

13. The method of aspect 12, wherein the atypical antidepressant isselected from the group consisting of aripiprazole, quetiapine andolanzapine.

14. A pharmaceutical composition for the treatment oftreatment-refractory or treatment-resistant depression comprisingesketamine, optionally at least one antidepressant, and a at least onepharmaceutically acceptable carrier.

15. The use of esketamine in the preparation of a medicament for thetreatment of treatment-refractory or treatment-resistant depression, ina patient in need thereof.

16. Esketamine for use in a method for the treatment oftreatment-refractory or treatment-resistant depression, in a patient inneed thereof.

17. A composition comprising esketamine for the treatment oftreatment-refractory or treatment-resistant depression.

18. A pharmaceutical product comprising esketamine for administration toa patient suffering from treatment resistant depression wherein theesketamine is administered intranasally to said patient in a clinicallyproven safe and effective amount.

19. A method of maintaining stable remission or stable response achievedby a patient with depression following administration of atherapeutically effective amount of esketamine during an initialadministration phase, comprising continuing administration of atherapeutically effective amount of esketamine for at least five monthsduring a subsequent administration phase.

20. The method of aspect 19, wherein the depression is treatmentresistant depression.

21. The method of aspect 19 or 20, wherein the therapeutically effectiveamount of esketamine is administered intranasally, intramuscularly,subcutaneously, transdermally, buccally, or rectally in the initial andsubsequent administration phases.

22. The method of aspect 21, wherein the administration is intranasally.

23. The method of any one of aspects 19 to 22, wherein a therapeuticallyeffective amount of at least one antidepressant is co-administered withthe esketamine in the initial and subsequent administration phases.

24. The method of aspect 23, wherein the esketamine is co-administeredwith one to two antidepressants.

25. The method of aspect 24, wherein each antidepressant is,independently, imipramine, amitriptyline, desipramine, nortriptyline,doxepin, protriptyline, trimipramine, maprotiline, amoxapine, trazodone,bupropion, comipramine, fluoxetine, duloxetine, escitalopram,citalopram, sertraline, paroxetine, fluvoxamine, nefazadone,venlafaxine, milnacipran, reboxetine, mirtazapine, phenelzine,tranylcypromine, moclobemide, Kava-Kava, St. John's Wart,s-adenosylmethionine, thyrotropin releasing hormone, a neurokininreceptor antagonist, or tiiodothyronine.

26. The method of any one of aspects 23-25, wherein each antidepressantis, independently, a mono-amine oxidase inhibitor, tricyclic, serotoninreuptake inhibitor, serotonin noradrenergic reuptake inhibitor,noradrenergic and specific serotonergic agent, or atypicalantidepressant.

27. The method of any one of aspects 23-26, wherein each antidepressantis, independently, phenelzine, tranylcypromine, moclobemide, imipramine,amitriptyline, desipramine, nortriptyline, doxepin, protriptyline,trimipramine, clomipramine, amoxapine, fluoxetine, sertraline,paroxetine, citalopram, fluvoxamine, venlafaxine, milnacipran,mirtazapine, or bupropion.

28. The method of any one of aspects 23-27, wherein each antidepressantis, independently, fluoxetine, imipramine, bupropion, venlafaxine, orsertraline.

29. The method of aspect 23, wherein the at least one antidepressant isan atypical antidepressant.

30. The method of aspect 29, wherein the atypical antidepressant isaripiprazole, quetiapine, olanzapine, risperdone, or paliperidone.

31. The method of aspect 30, wherein the atypical antidepressant isaripiprazole, quetiapine, or olanzapine.

32. The method of any one of aspects 19 to 31, wherein the initialadministration phase comprises an induction phase wherein the esketamineis administered at a frequency of at least twice a week.

33. The method of aspect 32, wherein the frequency is twice a week.

34. The method of aspect 32 or 33, further comprising assessing thepatient response during the induction phase.

35. The method of any one of aspects 32-34, wherein the initialadministration phase further comprises an optimization phase thatfollows the induction phase and wherein after the patient achieves asubstantially complete response to the esketamine during the inductionphase, the esketamine is administered at a frequency of less than twicea week during the optimization phase.

36. The method of aspect 35, further comprising assessing the patientresponse during the optimization phase and adjusting the frequency ofthe administration during the optimization phase based on the responsein order to achieve stable remission or stable response.

37. The method of aspect 36, wherein the frequency of administrationduring the optimization phase is once every week, once every two weeks,or a combination thereof.

38. The method of any one of aspects 19 to 37, wherein the effectiveamount of esketamine is 28 mg, 56 mg, or 84 mg during the initial andsubsequent administration phases.

39. The method of any one of aspects 32-38, wherein the continuingadministration of the esketamine during the subsequent administrationphase is for at least six months.

40. The method of any one of aspects 32-39, wherein the continuingadministration of the esketamine during the subsequent administrationphase is at least one year.

41. The method of any one of aspects 32-40, wherein the frequency ofadministration during the subsequent administration phase is once everyweek or once every two weeks, or a combination thereof.

42. The method of any one of aspects 32-41, wherein the effective amountof esketamine during the subsequent administration phase is 56 mg or 84mg.

43. The method of any one of aspects 32-42, wherein the dosing frequencyand effective amount of esketamine during the subsequent administrationphase is the minimum frequency and amount to maintain the stableremission or stable response.

44. The method of any one of aspects 19 to 43, wherein thetherapeutically effective amount of esketamine is a clinically provensafe and clinically proven effective amount.

45. A method for the long term treatment of depression in a patient,comprising administering to the patient in need of the treatment aclinically proven safe and clinically proven effective therapeuticallyeffective amount of esketamine for at least six months.

46. The method of aspect 45, wherein the esketamine is administered forat least one year.

47. The method of aspect 45 or 46, wherein the esketamine isadministered for up to two years.

48. The method of any one of aspects 45-47, wherein the depression istreatment resistant depression.

49. The method of any one of aspects 45-47, wherein the esketamine isadministered intranasally.

50. The method of any one of aspects 45-48, wherein a therapeuticallyeffective amount of at least one antidepressant is co-administered withthe esketamine.

51. The method of aspect 50, wherein the esketamine is co-administeredwith one to two antidepressants.

52. The method of aspect 51, wherein each antidepressant is,independently, imipramine, amitriptyline, desipramine, nortriptyline,doxepin, protriptyline, trimipramine, maprotiline, amoxapine, trazodone,bupropion, domipramine, fluoxetine, duloxetine, escitalopram,citalopram, sertraline, paroxetine, fluvoxamine, nefazadone,venlafaxine, milnacipran, reboxetine, mirtazapine, phenelzine,tranylcypromine, moclobemide, Kava-Kava, St. John's Wart,s-adenosylmethionine, thyrotropin releasing hormone, a neurokininreceptor antagonist, or triiodothyronine.

53. The method of any one of aspects 50-52, wherein each antidepressantis, independently, a mono-amine oxidase inhibitor, tricyclic, serotoninreuptake inhibitor, serotonin noradrenergic reuptake inhibitor,noradrenergic and specific serotonergic agent, or atypicalantidepressant.

54. The method of any one of aspects 50-53, wherein each antidepressantis, independently, phenelzine, tranylcypromine, moclobemide, imipramine,amitriptyline, desipramine, nortriptyline, doxepin, protriptyline,trimipramine, domipramine, amoxapine, fluoxetine, sertraline,paroxetine, citalopram, fluvoxamine, venlafaxine, milnacipran,mirtazapine, or bupropion.

55. The method of any one of aspects 50-54, wherein each antidepressantis, independently, fluoxetine, imipramine, bupropion, venlafaxine, orsertraline.

56. The method of aspect 55, wherein the at least one antidepressant isan atypical antidepressant.

57. The method of aspect 56, wherein the atypical antidepressant isaripiprazole, quetiapine, olanzapine, risperidone, or paliperidone.

58. The method of aspect 57, wherein the atypical antidepressant isaripiprazole, quetiapine, or olanzapine.

59. The method of any one of aspects 45-58, wherein the esketamine isinitially dosed twice a week for up to four weeks during an inductionphase, and, thereafter, dosed less frequently than twice a week.

60. The method of aspect 59, wherein the esketamine is dosed once a weekor once every two weeks following the induction phase.

61. The method of any one of aspects 45-60, wherein the therapeuticallyeffective amount of esketamine is 28 mg, 56 mg, or 84 mg.

62. The method of any one of aspects 45-61, wherein cognitiveperformance of the patient remains stable, based on a baselinemeasurement, following six months of treatment.

63. A method for treating major depressive disorder in an elderlypatient comprising

administering to the patient in need of treatment for a major depressivedisorder a therapeutically effective amount of esketamine at a frequencyof at least twice a week during an initial induction phase of definedduration;

assessing the patient response following the initial induction phase;and

continuing administering, at the frequency of at least twice a week,during an extended induction phase based on the assessment of whetherthe patient had achieved a substantially complete response toesketamine.

64. The method of aspect 63, wherein the elderly patient had notresponded to at least two oral antidepressants in the current depressiveepisode.

65. The method of aspect 64, wherein the therapeutically effectiveamount of esketamine is administered intranasally, intramuscularly,subcutaneously, transdermally, buccally or rectally.

66. The method of any one of aspects 63 to 65, wherein theadministration is intranasally.

67. The method of any one of aspects 63 to 66, wherein the initialinduction phase is up to 2 weeks.

68. The method of any one of aspects 63 to 66, wherein the initialinduction phase is up to 3 weeks.

69. The method of any one of aspects 63 to 66, wherein the initialinduction phase is up to 4 weeks

70. The method of any one of aspects 63 to 66, wherein the extendedinduction phase is up to 8 weeks.

71. The method of any one of aspects 63 to 70, wherein the effectiveamount 28 mg, 56 mg or 84 mg.

72. The method of any one of aspects 63 to 71, wherein after the elderlypatient has achieved a substantially complete response to esketamine,thereafter administering esketamine at a frequency of not more than oncea week during an optimization phase.

73. The method aspect 72, further comprising assessing the patient'sresponse periodically during the optimization phase.

74. The method of any one of aspects 63 to 73, wherein the frequency inthe initial induction phase, extended induction phase, or a combinationthereof is twice weekly.

75. The method of any one of aspects 63 to 74, wherein the majordepressive disorder is treatment refractory depression or treatmentresistant depression.

76. The method of any one of aspects 63 to 75, wherein a therapeuticallyeffective amount of at least one antidepressant is co-administered withesketamine.

77. The method of any one of aspects 63 to 76, wherein the combinationtherapy comprises esketamine and one to two antidepressants.

78. The method of aspect 77, wherein each antidepressant is,independently, imipramine, amitriptyline, desipramine, nortriptyline,doxepin, protriptyline, trimipramine, maprotiline, amoxapine, trazodone,bupropion, domipramine, fluoxetine, duloxetine, escitalopram,citalopram, sertraline, paroxetine, fluvoxamine, nefazadone,venlafaxine, milnacipran, reboxetine, mirtazapine, phenelzine,tranylcypromine, moclobemide, Kava-Kava, St. John's Wart,s-adenosylmethionine, thyrotropin releasing hormone, a neurokininreceptor antagonist, or triiodothyronine.

79. The method of aspect 77 or 78, wherein each antidepressant is,independently, a mono-amine oxidase inhibitor, tricyclic, serotoninreuptake inhibitor, serotonin noradrenergic reuptake inhibitor,noradrenergic and specific serotonergic agent, or atypicalantidepressant.

80. The method of any one of aspects 77 to 79, wherein eachantidepressant is, independently, phenelzine, tranylcypromine,moclobemide, imipramine, amitriptyline, desipramine, nortriptyline,doxepin, protriptyline, trimipramine, domipramine, amoxapine,fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine,venlafaxine, milnacipran, mirtazapine, or bupropion.

81. The method of any one of aspects 77 to 80, comprising one or twoantidepressants that are, independently, fluoxetine, imipramine,bupropion, venlafaxine, or sertraline.

82. The method of aspect 79, wherein the at least one antidepressant isan atypical antidepressant.

83. The method of aspect 82, wherein the atypical antidepressant isaripiprazole, quetiapine, olanzapine, risperidone, or paliperidone.

84. The method of aspect 82 or 83, wherein the atypical antidepressantis aripiprazole, quetiapine, or olanzapine.

85. The method of any one of aspects 63 to 84, wherein the patient is atleast 65 years of age.

86. A method for treating a patient with major depressive disorder,comprising administering to the patient in need of treatment for majordepressive disorder a clinically proven safe and clinically proveneffective therapeutically effective amount of esketamine.

87. The method of aspect 86, wherein the patient has not responded to atleast two oral antidepressants of adequate dose and duration in thecurrent depressive episode.

88. The method of aspect 86 or 87, wherein the patient has beendiagnosed with treatment refractory depression or treatment resistantdepression.

89. The method of aspect 86, wherein the patient has suicidal ideationas a symptom of major depressive disorder.

90. The method of aspect 89, wherein the patient is in imminent risk forsuicide.

91. The method of any one of aspects 86 to 90, wherein the patient is anadult.

92. The method of any one of aspects 86 to 91, wherein the patient is anelderly patient.

93. The method of any one of aspects 86 to 92, wherein the esketamine isadministered intranasally, intramuscularly, subcutaneously,transdermally, buccally or rectally.

94. The method of any one of aspects 86 to 93, wherein the esketamine isadministered intranasally.

95. The method of any one of aspects 86 to 94, wherein a therapeuticallyeffective amount of at least one antidepressant is co-administered withesketamine.

96. The method of aspect 95, wherein the esketamine is co-administeredwith one to two antidepressants.

97. The method of aspect 95 or 96, wherein each antidepressant is,independently, imipramine, amitriptyline, desipramine, nortriptyline,doxepin, protriptyline, trimipramine, maprotiline, amoxapine, trazodone,bupropion, clomipramine, fluoxetine, duloxetine, escitalopram,citalopram, sertraline, paroxetine, fluvoxamine, nefazadone,venlafaxine, milnacipran, reboxetine, mirtazapine, phenelzine,tranylcypromine, moclobemide, Kava-Kava, St. John's Wart,s-adenosylmethionine, thyrotropin releasing hormone, a neurokininreceptor antagonist, or triiodothyronine.

98. The method of aspect 95 or 96, wherein each antidepressant is,independently, a mono-amine oxidase inhibitor, tricyclic, serotoninreuptake inhibitor, serotonin noradrenergic reuptake inhibitor,noradrenergic and specific serotonergic agent, or atypicalantidepressant.

99. The method of any one of aspects 95 to 98, wherein eachantidepressant is, independently, phenelzine, tranylcypromine,moclobemide, imipramine, amitriptyline, desipramine, nortriptyline,doxepin, protriptyline, trimipramine, domipramine, amoxapine,fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine,venlafaxine, milnacipran, mirtazapine, or bupropion.

100. The method of any one of aspects 96 to 99, wherein eachantidepressant is, independently, fluoxetine, imipramine, bupropion,venlafaxine, or sertraline.

101. The method of aspect 95, wherein the at least one antidepressant isan atypical antidepressant.

102. The method of aspect 101, wherein the atypical antidepressant isaripiprazole, quetiapine, olanzapine, risperidone, or paliperidone.

103. The method of aspect 101 or 102, wherein the atypicalantidepressant is aripiprazole, quetiapine, or olanzapine.

104. A pharmaceutical composition for the treatment of major depressivedisorder, comprising esketamine, optionally at least one antidepressant,and at least one pharmaceutically acceptable carrier.

105. A pharmaceutical composition for the treatment of treatmentrefractory depression or treatment resistant depression, comprisingesketamine, optionally at least one antidepressant, and at least onepharmaceutically acceptable carrier.

106. A pharmaceutical composition for the treatment of suicidalideation, comprising esketamine, optionally at least one antidepressant,and at least one pharmaceutically acceptable carrier.

107. Use of esketamine in the preparation of a medicament for thetreatment of major depressive disorder in a patient in need thereof.

108. Use of aspect 107, wherein the patient is suffering from treatmentrefractory depression or treatment resistant depression.

109. Use of aspect 107, wherein the patient is suffering from suicidalideation.

110. Esketamine for use in a method for the treatment of majordepressive disorder in a patient in need thereof.

111. Esketamine of aspect 110, wherein the patient is suffering fromtreatment refractory depression or treatment resistant depression.

112. Esketamine of aspect 110, wherein the patient is suffering fromsuicidal ideation.

113. A composition comprising esketamine for the treatment of majordepressive disorder.

114. A composition comprising esketamine for the treatment of treatmentrefractory depression or treatment resistant depression.

115. A composition comprising esketamine for the treatment of suicidalideation.

116. A pharmaceutical product comprising esketamine for administrationto a patient suffering from major depressive disorder, wherein theesketamine is administered intranasally to said patient in a clinicallyproven safe and effective amount.

117. The pharmaceutical product of aspect 116, wherein the patient issuffering from treatment refractory depression or treatment resistantdepression.

118. The pharmaceutical product of aspect 116, wherein the patient issuffering from suicidal ideation.

119. A method of administering esketamine to a patient, comprising afirst phase, of a duration of about one week to about four weeks,wherein about 28 mg to about 84 mg of esketamine is administered to thepatient at a frequency of twice per week, and wherein the method isclinically proven safe.

120. The method of aspect 119, wherein about 28 mg of esketamine isadministered.

121. The method of aspect 119 or 120, wherein the administration of theesketamine achieves a maximum plasma concentration (C_(max)) ofesketamine of about 45 to about 75 ng/mL, an area under the plasmaconcentration-time curve from time 0 to time of last quantifiableconcentration (AUC_(last)) of about 125 to about 185 ng*h/mL, or acombination thereof.

122. The method of any one of aspects 119-121, wherein the esketamine isadministered intranasally.

123. The method of aspect 122, wherein the about 28 mg of esketamine isadministered in at least two sprays.

124. The method of aspect 123, wherein the about 28 mg of esketamine isadministered via one spray in each nostril.

125. The method of aspect 119, wherein about 56 mg of esketamine isadministered.

126. The method of aspect 119 or 125, wherein the administration of theesketamine achieves a maximum plasma concentration (C_(max)) ofesketamine of about 65 to about 120 ng/mL, an area under the plasmaconcentration-time curve from time 0 to time of last quantifiableconcentration (AUC_(last)) of about 210 to about 320 ng*h/mL, or acombination thereof.

127. The method of aspect 125 or 126, wherein the esketamine isadministered intranasally.

128. The method of aspect 127, wherein the about 56 mg of esketamine isadministered in at least 4 sprays.

129. The method of aspect 128, wherein the esketamine is administeredvia one spray in each nostril at time 0 for a total of about 28 mg, andrepeated after about 5 minutes for the total of about 56 mg.

130. The method of aspect 119, wherein about 84 mg of esketamine isadministered.

131. The method of aspect 119 or 130, wherein the administration of theesketamine achieves a maximum plasma concentration (C_(max)) ofesketamine of about 90 to about 165 ng/mL, an area under the plasmaconcentration-time curve from time 0 to time of last quantifiableconcentration (AUC_(last)) of about 305 to about 490 ng*h/mL, or acombination thereof.

132. The method of aspect 130 or 131, wherein the esketamine isadministered intranasally.

133. The method of aspect 132, wherein the about 84 mg of esketamine isadministered in at least 6 sprays.

134. The method of aspect 133, wherein the esketamine is administeredvia one spray in each nostril at time 0 for a total of about 28 mg,repeated after about 5 minutes for a total of about 56 mg, and repeatedagain after about 5 minutes for the total of about 84 mg in about 10minutes.

135. The method of any one of aspects 119 to 134, wherein the firstphase is a duration of about 4 weeks.

136. The method of any one of aspects 119 to 135, further comprising asecond phase, of a duration of about 1 to about 4 weeks, following thefirst phase, wherein about 56 mg to about 84 mg of esketamine isadministered to the patient at a frequency of once per week.

137. The method of aspect 136, wherein about 56 mg of esketamine isadministered to the patient at a frequency of once per week during thesecond phase.

138. The method of aspect 136, wherein about 84 mg of esketamine isadministered to the patient at a frequency of once per week during thesecond phase.

139. The method of any one of aspects 136-138, wherein the esketamine isadministered intranasally in the second phase.

140. The method of any one of aspects 136-139, wherein the second phaseis a duration of about 4 weeks.

141. The method of any one of aspects 119 to 140, further comprising athird phase, of a duration of about at least one week, following thesecond phase, wherein about 56 mg to about 84 mg of esketamine isadministered to the patient at a frequency of every 2 weeks or once perweek.

142. The method of aspect 141, wherein about 56 mg of esketamine isadministered to the patient at a frequency of every 2 weeks or once perweek during the third phase.

143. The method of aspect 141, wherein about 84 mg of esketamine isadministered to the patient at a frequency of every 2 weeks or once perweek during the third phase.

144. The method of any one of aspects 141-143, wherein the esketamine isadministered intranasally in the third phase.

145. The method of any one of aspects 141-144, wherein the third phaseis a duration of about at least one month.

146. The method of any one of aspects 141-144, wherein the third phaseis a duration of about at least two months.

147. The method of any one of aspects 141-144, wherein the third phaseis a duration of about at least three months.

148. The method of any one of aspects 141-144, wherein the third phaseis a duration of about at least four months.

149. The method of any one of aspects 141-144, wherein the third phaseis a duration of about at least five months.

150. The method of any one of aspects 141-144, wherein the third phaseis a duration of about at least six months.

151. The method of any one of aspects 141-144, wherein the third phaseis a duration of at least about a year.

152. The method of any one of aspects 141-144, wherein the third phaseis a duration of at least about two years.

153. The method of any one of aspects 119 to 152, wherein the methodfurther comprises co-administering an antidepressant, and wherein themethod is clinically proven effective to treat a major depressivedisorder.

154. The method of aspect 153, wherein the antidepressant isadministered orally.

155. The method of aspects 153 or 154, wherein the major depressivedisorder is treatment resistant depression.

156. A pharmaceutical product comprising one or more intranasal spraydevices, wherein the one or more devices comprise an esketaminecomposition and the one or more devices is configured to administer fromabout 28 to about 84 mg of esketamine, and wherein the pharmaceuticalproduct is clinically proven safe and/or clinically proven effective totreat a major depressive disorder.

157. The pharmaceutical product of aspect 156, wherein the majordepressive disorder is treatment resistant depression.

158. The pharmaceutical product of aspect 156 or 157, wherein theproduct comprises one device.

159. The pharmaceutical product of aspect 156, wherein the device isconfigured to administer the esketamine in two or more sprays.

160. The pharmaceutical product of aspect 158 or 159, wherein the devicecomprises about 28 mg of esketamine.

161. The pharmaceutical product of aspect 156, wherein the productcomprises more than one device and each device comprises about 28 mg ofesketamine.

162. The pharmaceutical product of aspect 161, wherein each device is asingle use device.

163. The pharmaceutical product of aspect 162, comprising three devices.

164. The pharmaceutical product of any one of aspects 156-163, furthercomprising instructions for performing any one of the methods of aspects119-155.

165. A method of treating major depressive disorder with suicidalideation, comprising

administering esketamine at a highest tolerable dose twice weekly duringa first induction phase of a defined duration;

administering a first oral antidepressant simultaneously with theesketamine; and

evaluating the patient to determine if a substantially complete responseto esketamine is achieved.

166. The method of aspect 165, wherein the treatment ceases if thepatient achieves a substantially complete response to the esketamine.

167. The method of aspect 166, wherein the patient is monitored toensure the patient remains stable or in remission on the first oralantidepressant alone.

168. The method of aspect 165, wherein a second induction phase isinitiated if a substantially complete response is not achieved duringthe first induction phase.

169. The method of aspect 168, wherein the patient is reinitiated onesketamine at the highest tolerable dose and simultaneously with asecond oral antidepressant during the second induction phase.

170. The method of aspect 169, wherein the second oral antidepressant isthe same as the first oral antidepressant.

171. The method of aspect 169, wherein the second oral antidepressant isdifferent than the first oral antidepressant.

172. The method of any one of aspects 169-171, wherein the patient ismonitored to ensure the patient remains stable or in remission on thesecond oral antidepressant alone.

173. The method of any one of aspects 169-172, wherein a third inductionphase is initiated if a substantially complete response is not achievedduring the second induction phase.

174. The method of aspect 173, wherein the patient is reinitiated onesketamine at the highest tolerable dose and simultaneously with a thirdoral antidepressant during the third induction phase.

175. The method of aspect 174, wherein the third oral antidepressant isthe same as the second oral antidepressant.

176. The method of aspect 174, wherein the third oral antidepressant isdifferent than the second oral antidepressant.

177. The method of any one of aspects 165-176, further comprisingadministering a therapeutically effective amount of esketamine to thepatient less than twice a week in a subsequent maintenance phase.

178. The method of any one of aspects 165-177, wherein the first,second, and third induction phase are, independently, at least 4 weeks.

179. A method for treating treatment-resistant depression in a patientwherein the patient has not responded to at least two oralantidepressants in the current depressive episode, the methodcomprising:

administering a first oral antidepressant to the patient, and

administering esketamine to the patient at least twice weekly during afirst induction phase of a defined duration;

evaluating the patient during the first induction phase; and

wherein the patient fails to achieve a substantially complete responseto the esketamine, reinitiating the patient on the highest tolerabledose of esketamine and simultaneously with a second oral depressant in asecond induction phase of a defined duration.

180. The method of aspect 179, wherein the first oral antidepressant isthe same as at least one of the at least two oral antidepressants.

181. The method of aspect 179, wherein the first oral antidepressant isdifferent than at least one of the at least two oral antidepressants.

182. The method of aspect 179, wherein the first oral antidepressant isdifferent than the at least two oral antidepressants.

183. The method of any one of aspects 179-182, wherein if the patientfails to achieve a substantially complete response to the esketamineduring the second induction phase, reinitiating the patient onesketamine and simultaneously with a third oral depressant in a thirdinduction phase of a defined duration.

184. The method of aspect 183, wherein the third oral antidepressant isthe same as the second oral antidepressant.

185. The method of aspect 183, wherein the third oral antidepressant isdifferent than the second oral antidepressant.

186. The method of any one of aspects 179-185, further comprising thatwhen the patient achieves a substantially complete response to theesketamine, administering a therapeutically effective amount ofesketamine to the patient at most once weekly during a subsequentmaintenance phase.

187. The method of any one of aspects 179-186, wherein the first,second, and third induction phase are, independently, at least 4 weeks.

188. A method of treating treatment-resistant depression in a patient,said method comprising:

administering a therapeutically effective amount of an oralantidepressant to said patient; and

intranasally administering a therapeutically effective amount ofesketamine to said patient at least twice weekly during an inductionphase of at least 4 weeks; and

intranasally administering a therapeutically effective amount ofesketamine to the patient at most once weekly during a subsequentmaintenance phase,

wherein the method is clinically proven safe and/or clinically proveneffective.

189. The method of aspect 188, wherein the esketamine is administeredonce every two weeks during the subsequent maintenance phase.

190. The method of aspect 188, wherein the frequency of administrationmay be adjusted during the induction phase and/or maintenance phase.

191. The method of aspect 188, wherein the therapeutically effectiveamount of esketamine administered during the induction phase is fromabout 28 mg to about 84 mg.

192. The method of aspect 191, wherein the therapeutically effectiveamount of esketamine is about 28 mg.

193. The method of aspect 191, wherein the therapeutically effectiveamount of esketamine is about 56 mg.

194. The method of aspect 191, wherein the therapeutically effectiveamount of esketamine is about 84 mg.

195. The method of aspect 191, wherein the therapeutically effectiveamount of esketamine is about 56 mg at the start of the induction phaseand is adjusted to about 84 mg during the induction phase.

196. The method of aspect 192, wherein the patient is 65 years or older.

197. The method of aspect 188, wherein the therapeutically effectiveamount of esketamine administered during the maintenance phase is about56 mg or about 84 mg.

198. The method of any one of aspects 188-197, wherein thetherapeutically effective amount of esketamine during the induction andmaintenance phase is delivered from an intranasal administration devicein 2 or more sprays.

199. The method of any one of aspects 188-198, wherein the treatmentcontinues for at least six months.

200. The method of any one of aspects 188-198, wherein the treatmentcontinues for up to two years.

As used herein, AD=antidepressant; AE=adverse event; ESK=esketaminenasal spray; PBO=placebo nasal spray; PHQ-9=Patient AdherenceQuestionnaire; SDS=Sheehan Disability Scale; CGI-S=Clinical GlobalImpression-Severity; MADRS=Montgomery-Asberg Depression Rating Scale;SD=standard deviation: SNRI=serotonin and norepinephrine reuptakeinhibitors; SSRI=selective serotonin reuptake inhibitors: LS=leastsquare; SE=standard error; BMI=body mass index; BPIC-SS=BladderPain/Interstitial Cystitis Symptom Score; BPRS+=4-item positive symptomsubscale of the Brief Psychiatric Rating Scale; C=clinic visit;CADSS=Clinician Administered Dissociative States Scale; CGADR=ClinicalGlobal Assessment of Discharge Readiness; C-SSRS=Columbia SuicideSeverity Rating Scale; DNA=deoxyribonucleic acid; ECG=electrocardiogram;EQ-5D-5L=EuroQol-5 dimension-5-level; EW=early withdrawal;GAD-7=Generalized Anxiety Disorder, 7-item scale; HE=haematoxylin andeosin stain; HbA1c test, glycated hemoglobin test; HRUQ=HealthcareResource Use Questionnaire; HVLT-R=Hopkins Verbal Learning Test-Revised;IDS-C₃₀=Inventory of Depressive Symptomatology Clinician-rated, 30-itemscale; LOE=lack of efficacy; MDD—major depressive disorder; LTF=lost tofollow-up; MGH-ATRQ=Massachusetts General Hospital-AntidepressantTreatment History Questionnaire; MGH-Female RLHQ=Massachusetts GeneralHospital-Female Reproductive Lifecyde and Hormones Questionnaire;MINI=Mini-International Neuropsychiatric Interview; MOAA/S=ModifiedObserver's Assessment of Alertness/Sedation; NS=not statisticallysignificant; OL=open-label; OTH=other reason for withdrawal; PAQ,Patient Adherence Questionnaire; PHQ-9=Patient Health Questionnaire-9;PWC-20=Physician Withdrawal Checklist, 20-item scale; QIDS=16-item QuickInventory of Depressive Symptoms-Self-Report; RNA=ribonudeic acid; SDS,Sheehan Disability Scale; SAFER=State vs. Trait, Assessibility, FaceValidity, Ecological Validity, Rule of Three P's; STOP-Bang=Snoring,Tired, Observed Apnea, High Blood Pressure, Body mass index, Age, NeckSize, Gender (a questionnaire); TRD=treatment resistant depression;TSH=thyroid-stimulating hormone; RA=remote assessments only; LOCF=lastobservation carried forward; WBP=withdrawal by patient; WD=withdrawn.

The following Examples are set forth to aid in the understanding of theinvention, and are not intended and should not be construed to limit inany way the invention set forth in the claims which follow thereafter.

Example 1 Efficacy of Intranasal Esketamine for Treating TreatmentResistance Depression (TRD), Phase 3 Clinical Trial

The ability of esketamine to treat treatment-refractory ortreatment-resistant depression (TRD) was evaluated via the clinicalstudy described below, which was conducted to evaluate the efficacy,safety, and tolerability of flexibly dosed intranasal esketamine plus anewly initiated oral antidepressant in adult subjects with TRD. Thestudy served as a pivotal Phase 3 short-term efficacy and safety studyin support of regulatory agency requirements for registration ofintranasal esketamine for the treatment of TRD.

The hypothesis for this study was that, in adult subjects with TRD,switching from a failed antidepressant treatment to intranasalesketamine plus a newly initiated oral antidepressant would be superiorto switching to a newly initiated oral antidepressant treatment (activecomparator) plus intranasal placebo in improving depressive symptoms.

The primary objective of this study was to evaluate the efficacy ofswitching adult subjects with TRD from a prior antidepressant treatment(to which they have not responded) to flexibly dosed intranasalesketamine (28 mg, 56 mg or 84 mg) plus a newly initiated oralantidepressant compared with switching to a newly initiated oralantidepressant (active comparator) plus intranasal placebo, in improvingdepressive symptoms, as assessed by the change from baseline in theMADRS total score from Day 1 (pre-randomization) to the end of the4-week double-blind induction phase.

The key secondary objectives were to assess the effect of intranasalesketamine plus a newly initiated oral antidepressant compared with anewly initiated oral antidepressant (active comparator) plus intranasalplacebo on the following parameters in adult subjects with TRD: (a)Depressive symptoms (subject-reported), (b) Onset of clinical responseby Day 2, and (c) Functioning and associated disability. Additionalsecondary objectives included (a) Depression response rates, (b)Depression remission rates, (c) Overall severity of depressive illness,(d) Anxiety symptoms and (e) Health-related quality of life and healthstatus.

To investigate the safety and tolerability of intranasal esketamine plusa newly initiated oral antidepressant compared with a newly initiatedoral antidepressant (active comparator) plus intranasal placebo in adultsubjects with TRD, the following parameters were also measured: (a)TEAEs, including AEs of special interest, (b) Local nasal tolerability,(c) Effects on heart rate, blood pressure, respiratory rate, and bloodoxygen saturation, (d) Effects on alertness and sedation, (e) Potentialpsychosis-like effects, (f) Dissociative symptoms, (g) Potential effectson cognitive function, (h) Potential effects on suicidalideation/behavior, (i) Potential treatment-emergent symptoms of cystitisand/or lower urinary tract symptoms, (j) Potential withdrawal and/orrebound symptoms following cessation of intranasal esketamine treatment,and (k) Potential effects on sense of smell.

The PK of intranasal esketamine in adult subjects with TRD receivingintranasal esketamine plus a newly-initiated oral antidepressant wasalso assessed as part of the secondary objectives.

Study Drug Information

Esketamine was supplied as a clear, colorless intranasal solution ofesketamine hydrochloride (16.14% weight/volume [w/v]; equivalent to 14%w/v of esketamine base) in a nasal spray pump. The solution consisted of161.4 mg/mL esketamine hydrochloride (equivalent to 140 mg of esketaminebase) formulated in 0.12 mg/mL ethylenediaminetetraacetic acid (EDTA)and 1.5 mg/mL citric acid at a pH of 4.5 in water for injection. It isprovided in a nasal spray pump, which delivered 16.14 mg esketaminehydrochloride (14 mg esketamine base) per 100-μL spray. Each individualnasal spray pump (device) contained a total of 28 mg (i.e., 2 sprays).

The placebo solution was supplied as a clear, colorless intranasalsolution of water for injection, with a bittering agent (denatoniumbenzoate [Bitrex®] at a final concentration of 0.001 mg/mL) added tosimulate the taste of the intranasal solution with active drug. Theplacebo solution was provided in matching nasal spray pump devices.Benzalkonium chloride was added as a preservative at a concentration of0.3 mg/mL. Each individual nasal spray pump (device) contained 2 sprays.

Oral Antidepressant Medications

Duloxetine 30 mg was obtained from commercial stock and provided underthe responsibility of the sponsor. Please refer to the packageinsert/SmPC for the physical description and a list of excipients.

Escitalopram 10 mg was obtained from commercial stock and provided underthe responsibility of the sponsor. Please refer to the packageinsert/SmPC for the physical description and a list of excipients.

Sertraline 50 mg and 25 mg (as applicable) were obtained from commercialstock and provided under the responsibility of the sponsor. Please referto the package insert/SmPC for the physical description and a list ofexcipients.

Venlafaxine 75 mg and 37.5 mg (as applicable) were obtained fromcommercial stock and provided under the responsibility of the sponsor.Please refer to the package insert/SmPC for the physical description anda list of excipients.

Overview of Study Design

This was a randomized, double-blind, active-controlled, multicenterstudy in male and female adult subjects with TRD to assess the efficacy,safety, and tolerability of flexibly dosed intranasal esketamine (28 mg,56 mg or 84 mg) plus a newly initiated oral antidepressant compared witha newly initiated oral antidepressant (active comparator) plusintranasal placebo. The study had 3 phases which are briefly describedbelow. A diagram of the study design is provided in FIG. 1.

Screening/Prospective Observational Phase (4-Week Duration)

This phase prospectively assessed treatment response to the subject'scurrent oral antidepressant treatment regimen. After 4 weeks ofcontinuing the same treatment regimen (at the same dosage), subjects whowere non-responders to their current oral antidepressant treatment (asassessed by independent, remote raters) were eligible to proceed to thedouble-blind induction phase. The site investigators were blinded to thestudy criteria for non-response.

Eligible subjects who entered the double-blind induction phasediscontinued their current oral antidepressant medication(s). Ifclinically indicated, a subject's current antidepressant medication(s)could be tapered and discontinued over an additional, optional period ofup to 3 weeks per the local prescribing information or clinicaljudgment.

As a new oral antidepressant was initiated on Day 1 of the double-blindinduction phase, eligible subjects who did not require a tapereddiscontinuation of their antidepressant medication(s) proceededimmediately into the double-blind induction phase.

Double-Blind Induction Phase (4-Week Duration)

The study included 227 randomized subjects (4 of whom did not receiveintranasal and/or oral AD study drug and were therefore not included inthe analysis sets), who were randomly assigned at a 1:1 ratio (n=98subjects per treatment arm) to receive double-blind treatment witheither intranasal esketamine or intranasal placebo. The intranasaltreatment sessions (esketamine or placebo) occurred twice weekly. Inaddition, all subjects initiated a new open-label oral antidepressant onDay 1 that was taken daily for the duration of this phase. The assignedoral antidepressant was 1 of 4 oral antidepressant medications(duloxetine, escitalopram, sertraline, or venlafaxine extended release[XR]), that the subject had not previously had a nonresponse to in thecurrent depressive episode, had not been previously intolerant to(lifetime), and was available in the participating country.

At the end of the induction phase, subjects who were responders (definedas 250% reduction in the MADRS total score from baseline [Day 1pre-randomization] to the end of the 4-week double-blind inductionphase) were eligible to participate in the subsequent studyESKETINTRD3003 if they met all other study entry criteria(ESKETINTRD3003 is a longer-term efficacy maintenance study involvingrepeated treatment sessions of intranasal esketamine).

If a subject withdrew from the study before the end of the double-blindinduction phase for reasons other than withdrawal of consent, an EarlyWithdrawal visit was conducted within 1 week of the date ofdiscontinuation, followed by the follow-up phase.

Follow-Up Phase (24-Week Duration)

This phase included all subjects who were not eligible or who chose tonot participate in the maintenance of effect study ESKETINTRD3003 andhad received at least 1 dose of intranasal study medication in thedouble-blind induction phase. There were no intranasal treatmentsessions administered during this phase.

At the start of the follow-up phase, further clinical/standard of carefor the treatment of depression were arranged by the study investigatorand/or the subject's treating physician. The decision to continue theoral antidepressant in this phase was at the discretion of theinvestigator, however, in order to better assess potential withdrawalsymptoms from intranasal study medication, it was recommended that theoral antidepressant medication be continued for at least the first 2weeks of the follow-up phase unless determined as not clinicallyappropriate.

The follow-up phase also allowed collection of additional informativedata to assess the course of the subject's major depressive episode overa 6-month period.

Taking into consideration the optional taper period of up to 3 weeks,the duration of a subject's study participation was 11 weeks (forsubjects continuing into ESKETINTRD3003) or 35 weeks (for subjectscompleting the follow-up phase).

Study Population

The inclusion criteria for enrolling subjects in this study were asfollows. Each potential subject satisfied all of the following criteriato be enrolled in the study.

-   -   1. At the time of signing the informed consent form (ICF),        subject was a man or woman 18 (or older if the minimum legal age        of consent in the country in which the study is taking place        is >18) to 64 years of age, inclusive.    -   2. At the start of the screening/prospective observational        phase, subject met the DSM-5 diagnostic criteria for        single-episode MDD (if single-episode MDD, the duration was ≥2        years) or recurrent MDD, without psychotic features, based upon        clinical assessment and confirmed by the MINI.    -   3. At the start of the screening/prospective observational        phase, subject had a history of nonresponse to ≥2 but ≤5 oral        antidepressant treatments in the current episode of depression,        assessed using the MGH-ATRQ and confirmed by documented medical        history and pharmacy/prescription records. Subject was taking an        oral antidepressant treatment with nonresponse at the start of        the screening/prospective observational phase. Subjects were        adherent to the continued oral antidepressant treatment        medication(s) (without adjustment in dosage) through the        screening/prospective observational phase, as documented on the        PAQ. Missing 24 days of antidepressant medication in the prior        2-week period was considered as inadequate adherence. Subjects        who were non-responders to their current oral antidepressant        medication(s) from the screening/prospective observational phase        (as assessed by independent, remote raters) were eligible for        randomization if all other entry criteria are met.    -   4. At the start of the screening/prospective observational        phase, subject had an IDS-C₃₀ total score of ≥34.    -   5. The subject's current major depressive episode, and        antidepressant treatment response in the current depressive        episode, was confirmed using a Site Independent Qualification        Assessment.    -   6. Subject was medically stable on the basis of physical        examination, medical history, vital signs (including blood        pressure), pulse oximetry, and 12-lead ECG performed in the        screening/prospective observational phase. If there were any        abnormalities that were not specified in the inclusion and        exclusion criteria, the determination of their clinical        significance was determined by the investigator and recorded in        the subject's source documents and initialed by the        investigator.    -   7. Subject was medically stable on the basis of clinical        laboratory tests performed in the screening/prospective        observational phase. If the results of the serum chemistry        panel, hematology, or urinalysis were outside the normal        reference ranges, the subject was included only if the        investigator judged the abnormalities or deviations from normal        to not be clinically significant or to be appropriate and        reasonable for the population under study. This determination        was recorded in the subject's source documents and initialed by        the investigator. Subjects with a pre-existing history of        thyroid disease/disorder who were treated with thyroid hormones        were on a stable dosage for 3 months prior to the start of the        screening/prospective observational phase and had        thyroid-stimulating hormone (TSH) within normal range in the        screening/prospective observational phase.    -   8. Subject were comfortable with self-administration of        intranasal medication and able to follow the intranasal        administration instructions provided.    -   9. Before the start of the screening/prospective phase, a female        subject was either (a) Not of childbearing potential:        Postmenopausal (>45 years of age with amenorrhea for at least 12        months or any age with amenorrhea for at least 6 months and a        serum follicle stimulating hormone (FSH) level >40 IU/L);        permanently sterilized (e.g., tubal occlusion, hysterectomy,        bilateral salpingectomy); or otherwise be incapable of        pregnancy; or (b) Of childbearing potential and practicing a        highly effective method of birth control consistent with local        regulations regarding the use of birth control methods for        subjects participating in clinical studies, e.g., established        use of oral, injected, or implanted hormonal methods of        contraception; placement of an intrauterine device (IUD) or        intrauterine system (IUS); barrier methods (e.g., condom with        spermicidal foam/gel/film/cream/suppository or occlusive cap        [diaphragm or cervical/vault caps] with spermicidal        foam/gel/film/cream/suppository); male partner sterilization        (the vasectomized partner should be the sole partner for that        subject); or true abstinence (when this is in line with the        preferred and usual lifestyle of the subject). If the        childbearing potential changed after start of the study (e.g.,        woman who was not heterosexually active became active), the        female subject began a highly effective method of birth control,        as described above. Women agreed to continue using these methods        of contraception throughout the study and for at least 6 weeks        after the last dose of intranasal study drug.    -   10. A woman of childbearing potential had a negative serum        (β-human chorionic gonadotropin [β-hCG]) at the start of the        screening/prospective observational phase and a negative urine        pregnancy test on Day 1 of the double-blind induction phase        prior to randomization.    -   11. A man who was sexually active with a woman of childbearing        potential and had not had a vasectomy agreed to use a barrier        method of birth control e.g., either condom with spermicidal        foam/gel/film/cream/suppository or partner with occlusive cap        (diaphragm or cervical/vault caps) with spermicidal        foam/gel/film/cream/suppository from Day 1 of the double-blind        induction phase (prior to randomization) through 3 months after        the last dose of intranasal study medication. Alternatively,        female partners of childbearing potential could practice a        highly effective method of birth control, e.g., established use        of oral, injected, or implanted hormonal methods of        contraception; placement of an intrauterine device (IUD) or        intrauterine system (IUS); or male partner sterilization. If the        childbearing potential changed after start of the study, a        female partner of a male study subject, began a highly effective        method of birth control, as described above.    -   12. Subject was willing and able to adhere to the prohibitions        and restrictions specified in the clinical trial protocol.    -   13. Each subject signed an ICF indicating that he or she        understood the purpose of and procedures required for the study        and was willing to participate in the study.

The exclusion criteria for enrolling subjects in this study were asfollows. Any potential subject who met any of the following criteria wasexcluded from participating in the study.

-   -   1. The subjects depressive symptoms had previously demonstrated        nonresponse to: (a) Esketamine or ketamine in the current major        depressive episode per clinical judgment, or (b) All of the oral        antidepressant treatment options available in the respective        country for the double-blind induction phase (i.e., duloxetine,        escitalopram, sertraline, and venlafaxine XR) in the current        major depressive episode (based on MGH-ATRQ), or (c) An adequate        course of treatment with electroconvulsive therapy (ECT) in the        current major depressive episode, defined as at least 7        treatments with unilateral ECT.    -   2. Subject has an implant for vagal nerve stimulation (VNS) or        had received deep brain stimulation (DBS) in the current episode        of depression.    -   3. Subject had a current or prior DSM-5 diagnosis of a psychotic        disorder or MDD with psychosis, bipolar or related disorders        (confirmed by the MINI), comorbid obsessive compulsive disorder,        intellectual disability (only DSM-5 diagnostic code 319),        borderline personality disorder, antisocial personality        disorder, histrionic personality disorder, or narcissistic        personality disorder.    -   4. Subject had homicidal ideation/intent, per the investigator's        clinical judgment, or had suicidal ideation with some intent to        act within 6 months prior to the start of the        screening/prospective observational phase, per the        investigator's clinical judgment or based on the C-SSRS,        corresponding to a response of “Yes” on Item 4 (active suicidal        ideation with some intent to act, without specific plan) or Item        5 (active suicidal ideation with specific plan and intent) for        suicidal ideation on the C-SSRS, or a history of suicidal        behavior within the past year prior to the start of the        screening/prospective observational phase. Subjects reporting        suicidal ideation with intent to act or suicidal behavior prior        to the start of the double-blind induction phase were excluded.    -   5. Subject had a history of moderate or severe substance or        alcohol use disorder according to DSM-5 criteria, except        nicotine or caffeine, within 6 months before the start of the        screening/prospective observational phase. A history (lifetime)        of ketamine, phencyclidine (PCP), lysergic acid diethylamide        (LSD), or 3, 4-methylenedioxy-methamphetamine (MDMA)        hallucinogen-related use disorder was exclusionary.    -   6. Subject had a current or past history of seizures        (uncomplicated childhood febrile seizures with no sequelae are        not exclusionary).    -   7. Subject had an UPSIT total score ≤18, indicative of anosmia,        during the screening/prospective observational phase.    -   8. Subject had one of the following cardiovascular-related        conditions: (a) Cerebrovascular disease with a history of stroke        or transient ischemic attack, (b) Aneurysmal vascular disease        (including intracranial, thoracic, or abdominal aorta, or        peripheral arterial vessels), (c) Coronary artery disease with        myocardial infarction, unstable angina, revascularization        procedure (e.g., coronary angioplasty or bypass graft surgery)        within 12 months before the start of the screening/prospective        observational phase, or planned revascularization procedure, (d)        Hemodynamically significant valvular heart disease such as        mitral regurgitation, aortic stenosis, or aortic regurgitation        or (e) New York Heart Association (NYHA) Class III-IV heart        failure of any etiology.    -   9. Subject had a history of uncontrolled hypertension despite        diet, exercise, or antihypertensive therapy at the start of the        screening/prospective observational phase or any past history of        hypertensive crisis or ongoing evidence of uncontrolled        hypertension defined as a supine systolic blood pressure        (SBP) >140 mmHg or diastolic blood pressure (DBP) >90 mmHg        during screening/prospective observational phase which continues        to be above this range with repeated testing during this phase.        On Day 1 of the double-blind induction phase prior to        randomization a supine SBP>140 mmHg or DBP>90 mmHg was also        exclusionary.    -   A potential subject may have had his/her current        antihypertensive medication regimen adjusted during the        screening/prospective observational phase and then re-evaluated        to assess their blood pressure control. The subject was on a        stable regimen for at least 2 weeks before Day 1 of the        double-blind induction phase.    -   10. Subject had a current or past history of significant        pulmonary insufficiency/condition or with an arterial blood        oxygen saturation (SpO₂) of <93% at the start of the        screening/prospective observational phase or Day 1 prior to        randomization.    -   11. Subject had clinically significant ECG abnormalities at the        start of the screening/prospective observational phase or on Day        1 of the double-blind induction phase prior to randomization,        defined as: (a) QT interval corrected according to Fridericia's        formula (QTcF): ≥450 msec, (b) Evidence of 2nd and 3rd degree AV        block, or 1st degree AV block with PR interval >200 msec, left        bundle branch block (LBBB), or right bundle branch block        (RBBB), (c) Features of new ischemia, (d) Arrhythmia (except        premature atrial contractions [PACs] and premature ventricular        contractions [PVCs]).    -   12. Subject had a history of additional risk factors for        Torsades des Pointes (e.g., heart failure, hypokalemia, family        history of Long QT Syndrome), or the use of concomitant        medications that prolong the QT interval/corrected QT (QTc)        interval    -   13. Subject had a history of, or symptoms and signs suggestive        of, liver cirrhosis (e.g., esophageal varices, ascites, and        increased prothrombin time) OR alanine aminotransferase (ALT) or        aspartate aminotransferase (AST) values ≥2× the upper limit of        normal or total bilirubin >1.5 times the ULN in the        screening/prospective observational phase. For elevations in        bilirubin if, in the opinion of the investigator and agreed upon        by the sponsor's medical officer, the elevation in bilirubin was        consistent with Gilbert's disease, the subject was able to        participate in the study.    -   14. Subject had positive test result(s) for drugs of abuse        (including barbiturates, methadone, opiates, cocaine,        phencyclidine, and amphetamine/methamphetamine) at the start of        the screening/prospective observational phase or Day 1 of the        double-blind induction phase prior to randomization. Subjects        who had a positive test result at screening due to        prescribed/over-the-counter opiates, barbiturates, or        amphetamines were permitted to continue in the        screening/prospective observational phase if the medication was        discontinued at least 1 week or 5 half-lives, whichever was        longer, before Day 1 of the double-blind induction phase (prior        to randomization) in accordance with restrictions as presented        to the investigator and reproduced in Table 6, below. The result        of the Day 1 (prior to randomization) test for drugs of abuse        had to be negative for the subject to be randomized. Retesting        was not permitted for positive test result(s), except for        reasons stated above. Prior intermittent use of cannabinoids        prior to the start of the screening/prospective observational        phase was not exclusionary as long as the subject did not meet        the criteria for substance use disorder. However, a positive        test result for cannabinoids pre-dose on Day 1 of the        double-blind induction phase was exclusionary.    -   15. Subject had uncontrolled diabetes mellitus or secondary        diabetes, as evidenced by HbA1c>9% in the screening/prospective        observational phase or history in the prior 3 months prior to        the start of the screening/prospective observational phase of        diabetic ketoacidosis, hyperglycemic coma, or severe        hypoglycemia with loss of consciousness.    -   16. Subject had untreated glaucoma, current penetrating or        perforating eye injury, brain injury, hypertensive        encephalopathy, intrathecal therapy with ventricular shunts, or        any other condition associated with increased intracranial        pressure or increased intraocular pressure or planned eye        surgery.    -   17. Subject had any anatomical or medical condition that may        impede delivery or absorption of intranasal study drug (e.g.,        significant structural or functional abnormalities of the nose        or upper airway; obstructions or mucosal lesions of the nostrils        or nasal passages; undergone sinus surgery in the previous 2        years).    -   18. Subject had an abnormal or unrepaired deviated nasal septum        with any 1 or more of the following symptoms: (a) Blockage of 1        or both nostrils in the past few months that can impact study        participation, (b) nasal congestion (especially 1-sided), (c)        frequent nosebleeds, (d) frequent sinus infections, or (e) noisy        breathing during sleep.    -   19. Subject had a history of malignancy within 5 years before        the start of the screening/prospective observational phase        (exceptions were squamous and basal cell carcinomas of the skin        and carcinoma in situ of the cervix, or malignancy that, in the        opinion of the investigator, with concurrence with the sponsor's        medical monitor, was considered cured with minimal risk of        recurrence).    -   20. Subject had known allergies, hypersensitivity, intolerance,        or contraindications to esketamine/ketamine and/or its        excipients or all of the available oral antidepressant treatment        options for the double-blind induction phase.    -   21. Subject had taken any prohibited therapies that would not        permit dosing on Day 1, as outlined in the section headed        Pre-study and Concomitant Therapy and Table 6.    -   22. Subject was taking a total daily dose of benzodiazepines        greater than the equivalent of 6 mg/day of lorazepam at the        start of the screening/prospective observational phase.    -   23. Subject had a score of ≥5 on the STOP-Bang questionnaire, in        which case obstructive sleep apnea needed to be ruled out (e.g.,        apnea-hypopnea index [AHI]<30). A subject with obstructive sleep        apnea could be included if he or she was using a positive airway        pressure device or other treatment/therapy that was effectively        treating his or her sleep apnea.    -   24. Subject had received an investigational drug (including        investigational vaccines) or used an invasive investigational        medical device within 60 days before the start of the        screening/prospective observational phase, or had participated        in 2 or more MDD or other psychiatric condition clinical        interventional studies in the previous 1 year before the start        of the screening/prospective observational phase, or was        currently enrolled in an investigational study.    -   25. Subject was a woman who was pregnant, breast-feeding, or        planning to become pregnant while enrolled in this study or        within 6 weeks after the last dose of intranasal study drug.    -   26. Subject had a diagnosis of acquired immunodeficiency        syndrome (AIDS). Human immunodeficiency virus (HIV) testing was        not required for this study.    -   27. Subject had any condition or situation/circumstance for        which, in the opinion of the investigator, participation would        not be in the best interest of the subject (e.g., compromise the        well-being) or that could prevent, limit, or confound the        protocol-specified assessments.    -   28. Subject had major surgery, (e.g., requiring general        anesthesia) within 12 weeks before the start of the        screening/prospective observational phase, or would not have        fully recovered from surgery, or had surgery planned during the        time the subject was expected to participate in the study.        Subjects with planned surgical procedures to be conducted under        local anesthesia were allowed to participate.    -   29. Subject was an employee of the investigator or study site,        with direct involvement in the proposed study or other studies        under the direction of that investigator or study site, as well        as family members of the employees or the investigator.

Investigators ensured that all study enrollment criteria were met. If asubject's status changed (including laboratory results or receipt ofadditional medical records) before the first dose of study drug wasgiven such that he or she no longer met all eligibility criteria, thenthe subject would be excluded from participation in the study.

Additionally, potential subjects had to be willing and able to adhere tothe following prohibitions and restrictions during the course of thestudy to be eligible for participation:

-   -   1. Inclusion and Exclusion Criteria;    -   2. Pre-Study and Concomitant Therapy Restrictions, including        list of Prohibited Concomitant Medications for Intranasal Study        Medication.    -   3. A positive urine drug screen for use of phencyclidine (PCP),        3, 4-methylenedioxy-methamphetamine (MDMA), or cocaine from Day        1 of the induction phase through the final visit in the        double-blind induction phase will lead to discontinuation.    -   4. Subjects had to abstain from using alcohol within 24 hours        before and after each intranasal treatment session. If a subject        appeared intoxicated, dosing should not occur.    -   5. On all intranasal study drug dosing days, all subjects had to        remain at the clinical study site until study procedures were        completed and the subject was ready for discharge, and had to be        accompanied by a responsible adult when released from the        clinical study site. Subjects were not to drive a car or work        with machines for 24 hours after study drug dosing.    -   6. Subjects were not to ingest grapefruit juice, Seville        oranges, or quinine for 24 hours before an intranasal dose of        study medication was to be administered.    -   7. ECT, DBS, transcranial magnetic stimulation (TMS), and VNS        were prohibited from study entry through the end of the        double-blind induction phase.    -   8. Subjects receiving psychotherapy were able to continue        receiving psychotherapy provided this therapy had been stable in        terms of frequency for the last 6 months prior to the        screening/prospective observational phase and remained unchanged        until the end of the double-blind induction phase.

Treatment Allocation, Randomization and Blinding

Central randomization was implemented in this study. Subjects wererandomly assigned to 1 of 2 treatment groups in a 1:1 ratio based on acomputer-generated randomization schedule prepared before the study byor under the supervision of the sponsor. The randomization was balancedby using randomly permuted blocks and was stratified by country andclass of oral antidepressant (SNRI or SSRI) to be initiated in thedouble-blind induction phase. The interactive web response system (IWRS)was assigned a unique treatment code, which dictated the treatmentassignment and matching study drug kits for the subject. After theinvestigator selected the oral antidepressant treatment for thedouble-blind induction phase, the site entered this information intoIWRS. The requestor used his or her own user identification and personalidentification number when contacting the IWRS, and was then given therelevant subject details to uniquely identify the subject.

The investigator was not provided with randomization codes. The codeswere maintained within the IWRS, which had the functionality to allowthe investigator to break the blind for an individual subject.

Data that could potentially unblind the treatment assignment (e.g.,intranasal study drug plasma concentrations, treatment allocation) washandled with special care to ensure that the integrity of the blind wasmaintained and the potential for bias was minimized. This could includemaking special provisions, such as segregating the data in question fromview by the investigators, clinical team, or others as appropriate untilthe time of database was lock and unblinding.

Under normal circumstances, the blind should not be broken until allsubjects had completed the study and the database was finalized.Otherwise, the blind could be broken only if specific emergencytreatment/course of action was dictated by knowing the treatment statusof the subject. In such cases, the investigator could in an emergencydetermine the identity of the treatment by contacting the IWRS. It wasrecommended that the investigator contact the sponsor or its designee,if possible, to discuss the particular situation, before breaking theblind. Telephone contact with the sponsor or its designee was available24 hours per day, 7 days per week. In the event the blind was broken,the sponsor was informed as soon as possible. The date and time of theunblinding was documented by the IWRS, and reason for the unblindingdocumented by the electronic case report form (eCRF) and in the sourcedocument. The documentation received from the IWRS indicating the codebreak was retained with the subject's source documents in a securemanner.

Subjects who had their treatment assignment unblinded were to continueto return for scheduled early withdrawal and follow up visits.

In general, randomization codes were disclosed fully only if the studywas completed and the clinical database was closed. For interimanalysis, the randomization codes and, if required, the translation ofrandomization codes into treatment and control groups were disclosed tothose authorized and only for those subjects included in the interimanalysis.

At the end of the double-blind induction phase the database was lockedfor the analysis and reporting of this phase. The subject treatmentassignment was revealed only to sponsor's study staff. The investigatorsand the site personnel were blinded to the treatment assignment untilall subjects had completed study participation through the follow-upphase.

To maintain the blinding of intranasal study medication, the esketamineand placebo intranasal devices were indistinguishable.

A total of 227 subjects were randomized in the study. Of these, 3subjects did not receive any study drug (intranasal or oral AD) and 1subject did not receive both the intranasal and oral AD study drug.

Demographic and baseline characteristics for the subjects in the studywere as listed in Table 1, below. In general, the treatment groups weresimilar with respect to the baseline characteristics. The majority ofsubjects entering the study were female, with a mean age of all subjectsof 45.7 years, ranging from 19 to 64 years.

TABLE 1 Demographic and Baseline Characteristics of Study Subjects OralAD + Intranasal Esk + Intranasal Placebo Total Oral AD (N = 114) (N =109) (N = 223) Age (years) N 114 109 223 Mean (SD) 44.9 (12.58) 46.4(11.14) 45.7 (11.89) Median 45.0 47.0 47.0 Range (19; 64) (20; 64) (19;64) Age category (years), n (%) N 114 109 223 18-44 54 (47.4%) 40(36.7%) 94 (42.2%) 45-64 60 (52.6%) 69 (63.3%) 129 (57.8%) Sex, n (%) N114 109 223 Male 39 (34.2%) 46 (42.2%) 85 (38.1%) Female 75 (65.8%) 63(57.8%) 138 (61.9%) Race, n (%) N 114 109 223 Asian 1 (0.9%) 1 (0.9%) 2(0.9%) Black or African American 6 (5.3%) 5 (4.6%) 11 (4.9%) White 106(93.0%) 102 (93.6%) 208 (93.3%) Multiple 1 (0.9%) 1 (0.9%) 2 (0.9%)Ethnicity, n (%) N 114 109 223 Hispanic or Latino 5 (4.4%) 7 (6.4%) 12(5.4%) Not Hispanic or Latino 108 (94.7%) 99 (90.8%) 207 (92.8%) NotReported 0 1 (0.9%) 1 (0.4%) Unknown 1 (0.9%) 2 (1.8%) 3 (1.3%) Baselineweight (kg) N 114 109 223 Mean (SD) 79.30 (20.140) 82.67 (19.468) 80.95(19.842) Median 73.10 84.90 79.70 Range  (48.9; 162.8)  (45.3; 147.0) (45.3; 162.8) Baseline height (cm) N 114 109 223 Mean (SD) 169.23(10.179) 169.81 (9.953) 169.51 (10.051) Median 168.15 167.00 168.00Range (148.5; 193.0) (151.0; 194.0) (148.5; 194.0) Baseline body massindex (kg/m²) N 114 109 223 Mean (SD) 27.5 (5.84) 28.6 (6.24) 28.1(6.05) Median 26.9 28.2 27.3 Range (16; 56) (18; 53) (16; 56) BMIcategory (kg/m²), n (%) N 114 109 223 Underweight <18.5 1 (0.9%) 2(1.8%) 3 (1.3%) Normal 18.5-<25 41 (36.0%) 28 (25.7%) 69 (30.9%)Overweight 25-<30 41 (36.0%) 36 (33.0%) 77 (34.5%) Obese 30-<40 28(24.6%) 39 (35.8%) 67 (30.0%) Morbidly obese ≥40 3 (2.6%) 4 (3.7%) 7(3.1%) Employment status, n (%) ^(a) N 114 109 223 Any type ofemployment 68 (59.6%) 63 (57.8%) 131 (58.7%) Any type of unemployment 34(29.8%) 35 (32.1%) 69 (30.9%) Other 12 (10.5%) 11 (10.1%) 23 (10.3%)Hypertension status, n (%) ^(b) N 114 109 223 Yes 18 (15.8%) 27 (24.8%)45 (20.2%) No 96 (84.2%) 82 (75.2%) 178 (79.8%) Country, n (%) N 114 109223 Czech Republic 30 (26.3%) 28 (25.7%) 58 (26.0%) Germany 10 (8.8%) 10(9.2%) 20 (9.0%) Poland 20 (17.5%) 18 (16.5%) 38 (17.0%) Spain 9 (7.9%)9 (8.3%) 18 (8.1%) United States 45 (39.5%) 44 (40.4%) 89 (39.9%)Region, n (%) N 114 109 223 Europe 69 (60.5%) 65 (59.6%) 134 (60.1%)North America 45 (39.5%) 44 (40.4%) 89 (39.9%) Class of oralantidepressant, n (%) N 114 109 223 SNRI 77 (67.5%) 75 (68.8%) 152(68.2%) SSRI 37 (32.5%) 34 (31.2%) 71 (31.8%) Oral antidepressant, n (%)N 114 109 223 Duloxetine 60 (52.6%) 61 (56.0%) 121 (54.3%) Escitalopram21 (18.4%) 17 (15.6%) 38 (17.0%) Sertraline 16 (14.0%) 16 (14.7%) 32(14.3%) Venlafaxine extended release (XR) 17 (14.9%) 15 (13.8%) 32(14.3%) ^(a) Any type of employment includes: any category containing“Employed”, Sheltered Work, Housewife or Dependent Husband, and Student;any type of unemployment includes: any category containing “Unemployed”;Other includes: Retired and No Information Available. ^(b) Hypertensionstatus is classified as Yes if hypertension is recorded in medicalhistory.

Of the 227 randomized subjects, 197 completed the 28-day double-blindinduction phase. The most frequent reason for withdrawal was adverseevent. Subsequently 86 subjects entered the follow-up phase and 118subjects continued into the ESKETINTRD3003 clinical study. Table 2 belowpresents the numbers and reasons for withdrawal from the study.

TABLE 2 Study Completion/Withdrawal Information; Double-blind InductionPhase Oral AD + Intranasal Esk + Intranasal Placebo Total Oral AD (N =116) (N = 111) (N = 227) Completed 98 (84.5%) 99 (89.2%) 197 (86.8%) Withdrawn 18 (15.5%) 12 (10.8%) 30 (13.2%) Adverse event 9 (7.8%) 1(0.9%) 10 (4.4%)  Lack of 2 (1.7%) 0 2 (0.9%) efficacy Lost to 1 (0.9%)1 (0.9%) 2 (0.9%) follow-up Protocol 2 (1.7%) 2 (1.8%) 4 (1.8%)violation Withdrawal by 4 (3.4%) 7 (6.3%) 11 (4.8%)  subject Other 0 1(0.9%) 1 (0.4%)

Baseline psychiatric history was as presented in table 3, below. Themean (SD) baseline MADRS total score was 37.1, ranging from 21 to 52.

TABLE 3 Baseline Psychiatric History Oral AD + Intranasal Esk +Intranasal Placebo Total Oral AD (N = 114) (N = 109) (N = 223) Age whendiagnosed with MDD (years) N 114 109 223 Mean (SD) 32.1 (12.53) 35.3(13.04) 33.7 (12.86) Median 30.5 36.0 33.0 Range  (8; 60)  (5; 64)  (5;64) Baseline MADRS total score N 114 109 223 Mean (SD) 37.0 (5.69) 37.3(5.66) 37.1 (5.67) Median 37.0 37.0 37.0 Range (22; 48) (21; 52) (21;52) Screening IDS-C30 total score N 114 109 223 Mean (SD) 46.0 (6.26)45.7 (5.89) 45.9 (6.07) Median 46.0 46.0 46.0 Range (34; 60) (35; 63)(34; 63) Baseline CGI-S N 114 109 223 Mean (SD) 5.0 (0.83) 5.1 (0.67)5.1 (0.75) Median 5.0 5.0 5.0 Range (0; 7) (4; 7) (0; 7) Baseline CGI-Scategory, n (%) N 114 109 223 Normal, not at all ill 0 0 0 Borderlinementally ill 0 0 0 Mildly ill 0 0 0 Moderately ill 21 (18.4%) 19 (17.4%)40 (17.9%) Markedly ill 64 (56.1%) 63 (57.8%) 127 (57.0%) Severely ill27 (23.7%) 26 (23.9%) 53 (23.8%) Among the most extremely ill patients 1(0.9%) 1 (0.9%) 2 (0.9%) Not assessed 1 (0.9%) 0 1 (0.4%) Baseline PHQ-9total score N 114 109 223 Mean (SD) 20.2 (3.63) 20.4 (3.74) 20.3 (3.68)Median 20.0 21.0 20.0 Range  (5; 27) (10; 27)  (5; 27) Screening C-SSRSlifetime ^(a), n (%) N 114 109 223 No event 65 (57.0%) 61 (56.0%) 126(56.5%) Suicidal ideation 40 (35.1%) 34 (31.2%) 74 (33.2%) Suicidalbehavior 9 (7.9%) 14 (12.8%) 23 (10.3%) Screening C-SSRS past 6 or 12months ^(a), n (%) N 114 109 223 No event 77 (67.5%) 74 (67.9%) 151(67.7%) Suicidal ideation (past 6 months) 37 (32.5%) 34 (31.2%) 71(31.8%) Suicidal behavior (past 12 months) 0 1 (0.9%) 1 (0.4%) Durationof current episode (wks) N 114 109 223 Mean (SD) 111.4 (124.28) 118.0(187.37) 114.6 (157.96) Median 63.5 52.0 0.0 Range  (9; 649)   (8; 1196)  (8; 1196) No. of previous antidepressant medications ^(b), n (%) N 114109 223 1 9 (7.9%) 18 (16.5%) 27 (12.1%) 2 69 (60.5%) 54 (49.5%) 123(55.2%) 3 24 (21.1%) 22 (20.2%) 46 (20.6%) 4 7 (6.1%) 13 (11.9%) 20(9.0%) 5 3 (2.6%) 1 (0.9%) 4 (1.8%) 6 1 (0.9%) 1 (0.9%) 2 (0.9%) 9 1(0.9%) 0 1 (0.4%) Family history of depression, n (%) N 114 109 223 Yes51 (44.7%) 56 (51.4%) 107 (48.0%) No 63 (55.3%) 53 (48.6%) 116 (52.0%)Family history of anxiety disorder, n (%) N 114 109 223 Yes 10 (8.8%) 16(14.7%) 26 (11.7%) No 104 (91.2%) 93 (85.3%) 197 (88.3%) Family historyof bipolar disorder, n (%) N 114 109 223 Yes 8 (7.0%) 11 (10.1%) 19(8.5%) No 106 (93.0%) 98 (89.9%) 204 (91.5%) Family history ofschizophrenia, n (%) N 114 109 223 Yes 6 (5.3%) 4 (3.7%) 10 (4.5%) No108 (94.7%) 105 (96.3%) 213 (95.5%) Family history of alcohol abuse, n(%) N 114 109 223 Yes 18 (15.8%) 20 (18.3%) 38 (17.0%) No 96 (84.2%) 89(81.7%) 185 (83.0%) Family history of substance abuse, n (%) N 114 109223 Yes 8 (7.0%) 4 (3.7%) 12 (5.4%) No 106 (93.0%) 105 (96.3%) 211(94.6%) ^(a) C-SSRS category: No event = 0; Suicidal ideation = 1, 2, 3,4, 5; Suicidal behavior = 6, 7, 8, 9, 10. ^(b) Number of antidepressantmedications with non-response (defined as ≤25% improvement) taken for atleast 6 weeks during the current episode as obtained from MGH-ATRQ.

Dosage and Administration Screening/Prospective Observational Phase

At the start of screening/prospective observational phase, subjects weretaking an oral antidepressant treatment with non-response at the startof the screening/prospective observational phase and continued this sametreatment for the duration of the phase to confirm nonresponse. The siteand investigators were blinded to the study criteria for non-response.During this phase, antidepressant treatment adherence was assessed usingthe PAQ.

After completion of 4 weeks of prospective antidepressant treatment andassessment of the antidepressant treatment response, the antidepressantmedication could be tapered and discontinued over a period of up to 3weeks per the local prescribing information or clinical judgment (e.g.,antidepressant treatments with short half-lives, such as paroxetine andvenlafaxine XR; or tolerability concerns).

Double-Blind Induction Phase

During this phase, subjects self-administered double-blind intranasaltreatment with esketamine (56 mg or 84 mg) or placebo twice per week for4 weeks as a flexible dose regimen at the study site. In addition,subjects simultaneously initiated a new, open-label oral antidepressant(i.e., duloxetine, escitalopram, sertraline, or venlafaxine XR) on Day 1that was continued for the duration of this phase.

Intranasal Study Drug

On all intranasal treatment sessions, a physician, nurse, or otherappropriate member of the site staff with recent training (i.e., within1 year) for cardiopulmonary resuscitation (CPR) was present with thesubject during the intranasal treatment session and the post-doseobservation period. In addition, equipment for supportive ventilationand resuscitation was present. Table 4, below describes how eachintranasal treatment session was to be administered in the double-blindinduction phase.

TABLE 4 Intranasal Treatment Administration during the Double-blindInduction Phase Intranasal Time of Intranasal Device AdministrationTreatment 0^(a) 5 minutes 10 minutes Intranasal 1^(st) 2^(nd) 3^(rd)Device^(b) Placebo 1 spray of 1 spray of 1 spray of placebo to placeboto placebo to each nostril each nostril each nostril Esketamine 1 sprayof 1 spray of 1 spray of 56 mg esketamine to esketamine to placebo toeach nostril each nostril each nostril Esketamine 1 spray of 1 spray of1 spray of 84 mg esketamine to esketamine to esketamine to each nostrileach nostril each nostril ^(a)Time 0 was defined as the time ofadministration of the first intranasal spray to one nostril from thefirst intranasal device. ^(b)One device was used at each time point.Each individual intranasal device contained 2 sprays. The intranasaldevices containing esketamine delivered 14 mg per spray, for a total of28 mg per individual device (i.e., 2 sprays).

Prior to the first intranasal dose on Day 1, subjects practiced spraying(into the air, not intranasally) a demonstration intranasal device thatwas filled with placebo solution.

All subjects self-administered the intranasal study drug (esketamine orplacebo) at treatment sessions twice a week for 4 weeks at the studysite. The first treatment session was on Day 1. Intranasal treatmentsessions did not take place on consecutive days.

On Day 1, subjects randomized to intranasal esketamine started with adose of 56 mg. On Day 4, the dose was increased to 84 mg or remained at56 mg, as determined by the investigator based on efficacy andtolerability. On Day 8, the dose was increased to 84 mg (if Day 4 dosewas 56 mg), remained the same, or was reduced to 56 mg (if Day 4 dosewas 84 mg), as determined by the investigator based on efficacy andtolerability. On Day 11, the dose was increased to 84 mg (if Day 8 dosewas 56 mg), remained the same, or was reduced to 56 mg (if Day 8 dosewas 84 mg), as determined by the investigator based on efficacy andtolerability. On Day 15, a dose reduction from 84 mg to 56 mg waspermitted, if required for tolerability; no dose increase was permittedon Day 15. After Day 15, the dose remained stable (unchanged).

Food was restricted for at least 2 hours before each administration ofstudy drug. Drinking of any fluids was restricted for at least 30minutes before the first nasal spray.

If the subject had nasal congestion on the dosing day, it wasrecommended that the dosing day be delayed (per the permitted visitwindow). Doses were not to be given on consecutive days. If anintranasal decongestant was used to reduce congestion, it could not beused within 1 hour prior to intranasal study drug dosing.

On all intranasal treatment sessions, subjects remained at the clinicalsite until study procedures had been completed and the subject was readyfor discharge and was accompanied by a responsible adult when releasedfrom the clinical study site. Subjects were not to drive a car or workwith machines for 24 hours after the last dose of intranasal study drugon each dosing day.

Oral Antidepressant Medication

Starting on Day 1, a new, open-label oral antidepressant treatment wasinitiated in all subjects and continued for the duration of this phase.The oral antidepressant was 1 of 4 oral antidepressant medications(duloxetine, escitalopram, sertraline, or venlafaxine XR). Theantidepressant medication was assigned by the investigator based on areview of the MGH-ATRQ and relevant information regarding priorantidepressant treatments, and was one that the subject has notpreviously had a non-response to in the current depressive episode, hadnot been previously intolerant to (lifetime), and was available in theparticipating country.

Dosing of the oral antidepressant began on Day 1 and followed the localprescribing information for the respective product, with a forcedtitration to the maximum tolerated dose. The protocol-specifiedtitration schedule was as presented in Table 5 below.

TABLE 5 Global titration schedule (except for Japan, Taiwan, SouthKorea, and Malaysia): Titration Schedule Active Comparator Week 1 Week 2Week 3 Week 4 Oral (Starting (Starting (Starting (StartingAntidepressant Day 1) Day 8) Day 15) Day 22) Duloxetine 60 mg  60 mg  60mg  60 mg Escitalopram 10 mg  20 mg  20 mg  20 mg Sertraline 50 mg 100mg 150 mg 150 mg Venlafaxine XR 75 mg 150 mg 225 mg 225 mg

If higher doses were not tolerated, a down-titration was permitted basedon clinical judgment. However, the subject's maximum tolerated doseshould not be lower than the following minimum therapeutic doses:Sertraline (50 mg/day), venlafaxine XR (150 mg/day), escitalopram (10mg/day), and duloxetine (60 mg/day). While subjects requiring lowerdoses could continue in the study and complete the double-blindinduction phase, such subjects were not eligible to participate in themaintenance of effect study ESKETINTRD3003 and proceeded to thefollow-up phase after completion of the double-blind induction phase.

All subjects were provided with an additional 4-week supply of the oralantidepressant medication to ensure there was no interruption ofantidepressant therapy during the transition to furtherclinical/standard of care.

Study-site personnel instructed subjects on how to administer and storethe oral antidepressant treatments supplied during the double-blindinduction phase for at-home use.

On intranasal treatment sessions, it was recommended that oralantidepressant treatment be taken in the evening and at the same time ofday during the double-blind induction phase. In addition, on intranasaldosing days, if the oral antidepressant medication frequency was greaterthan once daily (e.g., twice a day), it was recommended that the doseshould not be taken until at least 3 hours after the intranasaltreatment session.

Guidance on Blood Pressure Monitoring on Intranasal Dosing Days:

Given the potential for treatment emergent transient elevation insystolic and diastolic blood pressure, the following guidance wasfollowed on intranasal dosing days:

If subsequent to fulfilling the inclusion and exclusion criteria on Day1, a subject's pre-dose systolic blood pressure (SBP) was ≥160 mmHgand/or diastolic blood pressure (DBP) was ≥100 mmHg, it was recommendedto repeat the blood pressure measurement after subject rested for 10minutes in sitting or recumbent position. If repeated pre-dose SBP was≥160 mmHg and/or DBP is ≥100 mmHg, then dosing was postponed and thesubject scheduled to return on the following day or within the givenvisit window. If the blood pressure elevation persisted on the nextvisit, the subject was scheduled for a consultation by cardiologist orprimary care physician, prior to further dosing.

If at any post-dose time point on the dosing day, the SBP was ≥180 mmHgbut <200 mmHg and/or the DBP was 2110 mmHg but <120 mmHg, furtherintranasal dosing was interrupted and the subject was referred to acardiologist or primary care physician for a follow-up assessment.

After the assessment by a cardiologist or primary care physician, andprovided the subject was given approval to continue in the study, thesubject could continue with intranasal dosing if the pre-dose bloodpressure at the next scheduled visit was within the acceptable range.

If at any post-dose time point on the dosing day the SBP was ≥200 mmHgand/or the DBP was ≥120 mmHg, the subject was to discontinue fromfurther dosing and the subject referred to a cardiologist or primarycare physician for a follow-up assessment.

During the double-blind induction phase, at 1.5 hours post-dose, if theSBP was ≥160 mmHg and/or the DBP was ≥100 mmHg, assessments shouldcontinue every 30 minutes until the blood pressure was <160 mmHg SBP and<100 mmHg DBP or until the subject was referred for appropriate medicalcare, if clinically indicated.

Follow-Up Phase

Subjects who received at least 1 dose of intranasal study medication inthe double-blind induction phase, but did not enter the subsequentmaintenance clinical study ESKETINTRD3003, proceeded into the 24-weekfollow-up phase. No intranasal study medication was administered duringthis phase.

At the start of the follow-up phase, further clinical/standard of carefor the treatment of depression were arranged by the study investigatorand/or the subject's treating physician. The decision to continue theoral antidepressant medication in this phase was at the discretion ofthe investigator; however, in order to better assess potentialwithdrawal symptoms from intranasal study medication, it was recommendedthat the oral antidepressant medication be continued for at least thefirst 2 weeks of the follow-up phase unless determined as not clinicallyappropriate.

Treatment Compliance

The investigator or designated study-site personnel were required tomaintain a log of all intranasal study drug and oral antidepressantmedication dispensed and returned. Drug supplies for each subject wereinventoried and accounted for throughout the study.

Subjects received instructions on compliance with the oralantidepressant treatment. During the course of the study, theinvestigator or designated study-site personnel were responsible forproviding additional instruction to re-educate any subject to ensurecompliance with taking the oral antidepressant.

Antidepressant treatment adherence during the screening/prospectiveobservational phase was assessed using the PAQ. Missing 24 days ofantidepressant medication in the prior 2-week period was considered asinadequate adherence.

Antidepressant treatment compliance during the double-blind inductionphase was assessed by performing pill counts (i.e., compliance check)and drug accountability.

All doses of intranasal study drug was self-administered by the subjectsat the investigative site under the direct supervision of theinvestigator or designee, and will be recorded.

Pre-Study and Concomitant Therapy

Pre-study non-antidepressant therapies administered up to 30 days beforethe start of the screening/prospective observational phase were recordedat the start of this phase.

All antidepressant treatment(s), including adjunctive treatment for MDD,taken during the current depressive episode (i.e., including those takenmore than 30 days prior to the start of the screening/prospectiveobservational phase) were recorded at the start of thescreening/prospective observational phase. In addition, information wasalso obtained regarding any history of intolerance to any of the 4antidepressant choices (i.e., duloxetine, escitalopram, sertraline, andvenlafaxine XR).

Concomitant therapies were recorded throughout the study, beginning withsigning of the informed consent and continuing up to the last follow-upvisit. Information on concomitant therapies were also obtained beyondthis time only in conjunction with new or worsening adverse events untilresolution of the event.

Subjects continued to take their permitted concomitant medications(e.g., antihypertensive medications) at their regular schedule; however,subject to restrictions and Table 6, below were to taken into account.Of note, if oral antihypertensive medications were taken in the morning,the morning dose was to be taken on intranasal dosing days.

Subjects receiving psychotherapy could continue receiving psychotherapyprovided this therapy had been stable in terms of frequency for the last6 months prior to the start of the screening/prospective observationalphase and remained unchanged until after completion of the double-blindinduction phase.

All therapies (prescription or over-the-counter medications, includingvaccines, vitamins, herbal supplements; nonpharmacologic therapies, suchas psychotherapy, electrical stimulation, acupuncture, special diets,and exercise regimens) different from the study drug were recorded.Modification of an effective preexisting therapy should not be made forthe explicit purpose of entering a subject into the study, unlesspermitted by protocol (e.g., adjustment of blood pressure medications).

Rescue Medications

Rescue medications were not supplied by the sponsor. In case oftreatment-emergent adverse events that could not be resolved by stoppingfurther administration of intranasal esketamine/placebo, the followingrescue medications could be considered:

For agitation or anxiety: As required, midazolam (maximum dose 2.5 mgorally or IM) or short acting benzodiazepine

For nausea: As required, ondansetron 8 mg sublingually, metoclopramide(10 mg orally or IV or IM) or dimenhydrinate (25 to 50 mg, IV or IM)

It was recommended that transient increases in blood pressure not betreated, as the blood pressure returns to pre-dose values typically in 2hours. The effect of any treatment may result in hypotension.

Prohibited Medications

A list of prohibited medications (not all inclusive) was provided asgeneral guidance for the investigator and is reproduced in Table 6,below. The sponsor was notified in advance (or as soon as possiblethereafter) of any instances in which prohibited therapies wereadministered.

TABLE 6 Prohibited Concomitant Medications with Intranasal StudyMedication Episodic Use (as Continuous Reason for Drug Class needed) UseComments Prohibition Amantadine N N PD interaction Anorexiants N NSafety (eg, phentermine) Anticholinesterase N N Subject inhibitorspopulation is excluded Anticonvulsants N N Subjects with seizures areSafety and PD excluded. Use as adjunctive interaction treatment formajor depressive disorder (MDD) is prohibited. Note: Anticonvulsantsused for indications other than seizures may be allowed (eg, valproatefor migraine) Antidepressants N N Only 1 of the 4 predefined oral Safetyand PD (other than the antidepressant treatment interaction specificoptions are permitted antidepressant If a subject is taking a started inthe monoamine oxidase inhibitor induction phase of (MAOI) during the thestudy) screening/prospective observational phase, there must be aminimum washout interval of 2 weeks prior to the first dose ofintranasal study medication. Antipsychotics N N PD interactionBenzodiazepines Y Y Benzodiazepines are prohibited Safety and PD andnon- within 12 hours prior to the start interaction benzodiazepine ofeach intranasal treatment sleeping session or cognition testingmedication Non-benzodiazepine sleeping (including: medications areprohibited zolpidem, within 12 hours prior to the start zaleplon, ofcognition testing but are eszopiclone, and permitted the night beforeramelteon) dosing if no cognitive testing is scheduled. Benztropine Y NProhibited if use is continuous Safety and PD and prohibited within 12hours interaction. prior to the start of cognition testing Chloralhydrate, N N Safety and PD melatonin, interaction valerian Clonidine N NSafety and PD interaction Corticosteroids N N Inhaled, intranasal,topical, and PD interaction (oral) ophthalmic steroids are notprohibited. Cough/cold Y Y Intranasally-administered preparations/nasaldecongestants solutions (vasoconstrictors) should not be containing usedfrom 1 hour prior to each vasoconstrictors, intranasal study medicationdecongestants administration. CYP3A4 inhibitors N N Subjects may nottake a known PK Potent potent inhibitor of hepatic CYP3A activity within1 week or within a period less than 5 times the drug's half-life,whichever is longer, before the first administration of study medicationuntil at least 24 hours after the last intranasal dose of studymedication Examples (not all-inclusive): Indinavir, nelfinavir,ritonavir, clarithromycin, itraconazole, ketoconazole, nefazodone,saquinavir, and telithromycin CYP3A4 inducers N N Subjects may not takea known PK Potent potent inducer of hepatic CYP3A activity within 2weeks of the first administration of intranasal study medication untilat least 24 hours after the last intranasal dose of study medication.Examples (not all-inclusive): Efavirenz, nevirapine, barbiturates,carbamazepine, glucocorticoids, modafinil, oxcarbazepine, phenobarbital,phenytoin, rifabutin, rifampin, and St. John's wort Dextromethorphan N NPD interaction Diphenhydramine Y N Prohibited within 12 hours priorSafety to the start of each intranasal treatment session Ketanserin N NSafety Lithium N N PD interaction Memantine N N PD interactionMethyldopa N N Safety and PD Interaction Metyrosine N N Safety and PDinteraction Opioids N N PD interaction Psychostimulants N NCardiovascular (eg, safety amphetamines) Reserpine N N PD interactionScopolamine N N PD interaction St. John's Wort N N PD interaction and PKThyroid hormone N Y Subjects needing supplements Safety supplement formust be on a stable thyroid treatment of supplement dose for at least 6thyroid condition weeks prior to the first only (not for intranasaltreatment session depression) Thyroxine/ N N PD interactiontriiodothyronine (T3), thyroid hormone prescribed for depressionWarfarin N N Primary condition where used is excluded Abbreviations: N,Prohibited; PD, pharmacodynamics; PK, pharmacokinetics; Y, Permitted,with restrictions (please refer to the column labeled “Comments” foradditional guidance).

The number of doses of intranasal study medication is summarized inTable 7, below.

TABLE 7 Number of Days Dosed with Intranasal Study Medication;Double-blind Induction Phase (Study ESKETINTRD3002: Safety Analysis Set)Oral AD + Number of Intranasal Esk + Intranasal Placebo days dosed OralAD (N = 115) (N = 109) 1 6 (5.2%) 1 (0.9%) 2 0 2 (1.8%) 3 2 (1.7%) 1(0.9%) 4 2 (1.7%) 2 (1.8%) 5 2 (1.7%) 2 (1.8%) 6 0 2 (1.8%) 7 9 (7.8%) 6(5.5%) 8 94 (81.7%) 93 (85.3%)

A summary of mean, mode and final dose of intranasal study medication issummarized in Table 8, below.

TABLE 8 Mean, Mode, and Final Daily Dose of Intranasal Study Medication;Double-blind Induction Phase (Study ESKETINTRD3002: Safety Analysis Set)Intranasal Esk + Oral AD (N = 115) Mean daily dose (mg) N 115 Mean (SD)70.7 (10.64) Median   77.0 Range (56; 81) Mode daily dose (mg) N 109Mean (SD) 74.5 (13.32) Median   84.0 Range (56; 84) Final daily dose(mg) N 115 Mean (SD) 73.7 (13.51) Median   84.0 Range (56; 84) Thecalculation of mean, mode, and final daily dose excludes days offintranasal study medication. The final dose is the last non-zero dosereceived during the double-blind induction phase.

On Day 25 of the Double-blind Induction phase 66/99 (66/7%) subjectswere receiving the 84 mg dose of esketamine. Of the 115 subjects treatedwith intranasal esketamine, 11 (9.6%) of subjects decreased their doseduring the double-blind phase. Duration of exposure to oralantidepressant study medication was as summarized in Table 9, below.

TABLE 9 Extent of Exposure to Oral Antidepressant; Double-blindInduction Phase (Study ESKETINTRD3002: Safety Analysis Set) Serotoninand Norepinephrine Reuptake Inhibitors (SNRI) Duloxetine Venlafaxine XRTotal Intranasal esk + (N = 60) (N = 17) (N = 77) oral AD Totalduration, days Category, n (%)  ≤7 1 (1.7%) 0 1 (1.3%)  8-14 2 (3.3%) 1(5.9%) 3 (3.9%) 15-21 1 (1.7%) 0 1 (1.3%) 22-28 37 (61.7%) 7 (41.2%) 44(57.1%) >28 19 (31.7%) 9 (52.9%) 28 (36.4%) Mean (SD) 26.8 (4.91) 27.6(4.73) 27.0 (4.85) Median 28.0  29.0 28.0 Range (1; 30) (10; 32) (1; 32)Oral AD + (N = 61) (N = 15) (N = 76) intranasal placebo Total duration,days Category, n (%)  ≤7 2 (3.3%) 0 2 (2.6%)  8-14 0  0 0  15-21 1(1.6%) 0 1 (1.3%) 22-28 30 (49.2%) 8 (53.3%) 38 (50.0%) >28 28 (45.9%) 7(46.7%) 35 (46.1%) Mean (SD) 28.0 (5.99) 28.6 (1.12) 28.2 (5.38) Median28.0  28.0 28.0 Range (4; 48) (27; 31) (4; 48) Selective SerotoninReuptake Inhibitors (SSRI) Escitalopram Sertraline Total Intranasalesk + (N = 21) (N = 16) (N = 37) oral AD Total duration, days Category,n (%)  ≤7 1 (4.8%) 2 (12.5%) 3 (8.1%) 8-14 0 1 (6.3%) 1 (2.7%) 15-21 0 1(6.3%) 1 (2.7%) 22-28 12 (57.1%) 3 (18.8%) 15 (40.5%) >28 8 (38.1%) 9(56.3%) 17 (45.9%) Mean (SD) 26.8 (4.74) 23.8 (9.50) 25.5 (7.24) Median28.0  29.0  28.0  Range  (7; 29) (1; 30) (1; 30) Oral AD + (N = 17) (N =16) (N = 33) intranasal placebo Total duration, days Category, n (%)  ≤70 0 0  8-14 1 (5.9%) 1 (6.3%) 2 (6.1%) 15-21 0 0 0 22-28 10 (58.8%) 8(50.0%) 18 (54.5%) >28 6 (35.3%) 7 (43.8%) 13 (39.4%) Mean (SD) 27.8(4.27) 27.3 (4.99) 27.5 (4.56) Median  28.0  28.0  28.0 Range (14; 37)(9; 31) (9; 37) Percentages are calculated with the number of subjectsin each treatment group as the denominator. The duration of exposure isdefined as the duration between the date of the first antidepressantexposure and the date of the last antidepressant exposure. It includesdays on which subjects did not actually take medication.

Study Evaluations

The Time and Events Schedule was as presented in Table 10 and Table 11below, summarizes the frequency and timing of efficacy, PK, biomarker,pharmacogenomic, medical resource utilization, health economic, andsafety measurements applicable to this study.

TABLE 10 Time and Events Schedule (SCREENING/PROSPECTIVE OBSERVATIONALPHASE AND DOUBLE-BLIND INDUCTION PHASE) Screening/ProspectiveObservational Phase Double-blind Induction Phase Visit number 1.1 1.21.3 ^(a) 2.1 ^(a) 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 EW ^(b) Week Week1 Week 2 End of 1 2 3 4 — Week 4 Study day — — — 1 (base- 2  4  8 11 1518 22 25 28 EW line) Clinic visit window (in — ±2 ±2 — — ±1 ±1 ±1 ±1 ±1±1 +1 −1 — days) Remote MADRS — −2 −2 −2 ^(d) — —   −2 ^(c) —   −2 ^(c)—   −2 ^(c) — −1 — interview window (in days) Clinic visit (C) or C C CC RM C C C C C C C C C remote MADRS interview only (RM)Screening/Administrative Informed consent (ICF) X Medical history, Xpsychiatric history, demographics, employment status MINI X MGH-ATRQ XSite Independent X Qualification Assessment Height X Inclusion/exclusionX X criteria Pre-study therapy X Preplanned X surgery/proceduresSTOP-Bang X questionnaire (including assessment of BMI and neckcircumference) MGH-Female RLHQ: X Module I IDS-C30 X Study DrugRandomization X Dispensing of new oral X antidepressant (duloxetine,escitalopram, sertraline, or venlafaxine XR) Practice session for   X^(c) use of intranasal device Intranasal esketamine X X X X X X X X orplacebo Drug accountability X X X X X X X X X (intranasal studymedication) Drug accountability X X X (oral antidepressant studymedication) Oral antidepressant X X X X X compliance check SafetyAssessments (Clinician) Physical examination X X X X Nasal examination^(c) X X X X Vital signs: blood X X X X X X X X X X pressure, pulse,respiratory rate, temperature ^(c) Vital signs (postdose): X X X X X X XX blood pressure, pulse, respiratory rate ^(e) Weight X X X X 12-leadECG ^(f) X X X X X X C-SSRS: Baseline/ X Screening version C-SSRS: Sincelast X X X X X X X X X X X X visit version MOAA/S and pulse X X X X X XX X X oximetry ^(g) BPRS+ ^(h) X X X X X X X X CADSS ^(h) X X X X X X XX CGADR ^(i) X X X X X X X X PWC-20  X ^(j) X Safety Assessments(Subject-completed) Nasal symptom X X X X X guestionnaire ^(k) BPIC-SS^(c) X X X X Assessment of Sense of Smell UPSIT ^(c) X X X X SmellThreshold Test ^(c) X X X Efficacy Assessments (Clinician) MADRS (7-dayrecall; X X X   X ^(d) X X X X X performed by independent, remoteraters) MADRS (24-hr recall; X performed by independent, remote raters)CGI-S ^(c) X X X X X X X X X Subject-completed Assessments PAQ X X XPHQ-9 ^(c) X X X X X SDS ^(c) X X X X GAD-7 ^(c) X X X X EQ-5D-5L ^(c) XX X X X Cognition Testing Practice sessions X Computerized test X X Xbattery and HVLT-R Clinical Laboratory Assessments TSH, HbA1c X Lipidpanel (fasting) X Hematology, chemistry ^(c) X X X X Urine drug screen^(c) X X X X Alcohol breath test X X Urinalysis ^(c) X X X X X Serumpregnancy test X Urine pregnancy test ^(c) X X X X PharmacokineticsBlood collection ^(l) X X Biomarker, Pharmacogenomic (DNA), andExpression (RNA) Evaluations Blood sample collection X X X X X (protein)^(c, m) Blood sample collection X X X (DNA) ^(c, m) Blood samplecollection X X X X X (RNA) ^(c, m) Ongoing Subject Review Concomitanttherapy Ongoing Adverse events Ongoing Other Menstrual cycle X X Xtracking (start date of last menstrual period prior to study visit)Additional supply of X X oral antidepressant On intranasal dosing days,time 0 was defined as the time of the first intranasal spray. Therefore,postdose time points were referenced from this. ^(a) An additional,optional period of up to 3 weeks was permitted to taper and discontinuecurrent antidepressant medication(s) after completion of the Week 4(Visit 1.3) assessments, per the local prescribing information orclinical judgment. Subjects who did not require a taper and were thuseligible to immediately proceed to the double-blind induction phase willhave Visit 1.3 and Visit 2.1 occurring on the same day. ^(b) If asubject withdrew before the end of the double-blind induction phase(i.e., before completing Visit 2.10/Day 28) for reasons other thanwithdrawal of consent, an early withdrawal visit was conducted within 1week of the date of discontinuation, followed by the follow-up phase. Ifthe early withdrawal visit was conducted on the same day as a scheduledvisit, duplicate assessments were not required. ^(c) Pre-dose (if/whenperformed on intranasal dosing days). With the exception of post-doseassessments, subject-reported outcome assessments were administeredbefore all other study-related procedures during a clinic visit. ^(d)Performed only for subjects requiring a taper period during thescreening/prospective observational phase; the result was considered asthe subject's baseline MADRS for the double-blind induction phase. Forall other subjects, the baseline MADRS for the double-blind inductionphase was the MADRS performed at the end of Week 4 of thescreening/prospective observational phase. ^(e) Post-dose vital signswere performed at 40 minutes, 1 hour, and 1.5 hours post-dose. ^(f)Twelve-lead ECG was performed pre-dose and at t = 1 hour post-dose atVisit 2.1. Twelve-lead ECG were performed at t = 1 hour post-dose atVisits 2.3 to 2.9, but no pre-dose ECGs were required at Visits 2.3 to2.9. A time window of ±15 minutes was permitted. ^(g) The MOAA/S was notperformed at Visit 1.1 (pulse oximetry only). The MOAA/S was performedevery 15 minutes from pre-dose to t = +1.5 hours post-dose. Pulseoximetry was performed every 15 minutes from pre-dose to t = 1.5 hourspost-dose. ^(h) The BPRS+ and CADSS were performed pre-dose and at 40minutes and 1.5 hours post-dose. ^(i) CGADR was performed at 1 hour and1.5 hour post-dose; if the response is not “Yes” at 1.5 hour post-dose,the assessment was repeated every 15 minutes until a “Yes” response wasachieved or until the subject was referred for appropriate medical careif clinically indicated. A subject was not to be discharged prior to the1.5 hour time point. ^(j) PWC-20 was performed only if the subject wasnot continuing into Study ESKETINTRD3003. ^(k) Nasal symptomquestionnaire was performed pre-dose and at 1 hour post-dose. ^(l) PKblood collection was performed at t = 40 minutes and t = 2 hourspost-dose (where time = 0 was defined as the time of the firstintranasal spray). ^(m) Blood samples were collected prior to dosing. Itwas preferred that subjects adhere to a low fat diet on the day ofsample collection.

TABLE 11 Time and Events Schedule (FOLLOW-UP PHASE) Follow-up PhaseVisit number 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13Weeks after last  1  2  4  6  8 10 12 14 16 18 20 22 24 intranasal doseVisit window for ±3 ±3 ±3 ±3 ±3 ±3 ±3 ±3 ±3 ±3 ±3 ±3 ±3 clinic visit orremote assessments only (days) Clinic visit (C) or RA C RA RA RA RA C RARA RA RA RA C remote assessments only (RA) Oral antidepressantcompliance ^(a) Oral X antidepressant compliance check SafetyAssessments (Clinician-completed) Physical X X examination Nasal Xexamination Vital signs: Blood X X pressure, pulse, respiratory rate,temperature 12-lead ECG X C-SSRS: Since X X X last visit version PWC-20X ^(c) X Safety Assessments (Subject-completed) BPIC-SS X EfficacyAssessments (Clinician-completed) MADRS X (performed by independent,remote raters) CGI-S X X X Efficacy Assessments (Subject-completed)PHQ-9 X X X X X X X SDS X X X X X X X GAD-7 X X X X X X X EQ-5D-5L X X XX X X X Cognition testing Computerized test X battery and HVLT-R MedicalResource Utilization HRUQ ^(b) X X X X X X X X X X X X ClinicalLaboratory Assessments Hematology, X chemistry Urinalysis X Serumpregnancy X test Biomarker and Expression (RNA) Evaluations Blood sampleX collection (protein) ^(d) Blood sample X collection (RNA) ^(d) OngoingSubject Review Concomitant Ongoing therapy Adverse events Ongoing Nointranasal study medication was administered during the follow-up phase.^(a) In order to better assess potential withdrawal symptoms fromintranasal study medication, it was recommended that the oralantidepressant medication be continued for at least the first 2 weeks ofthe follow-up phase unless determined to be not clinically appropriate.^(b) For the HRUQ, a clinician-completed assessment was required (basedon subject-responses). ^(c) Performed by telephone by qualified sitestaff. ^(d) It was preferred that subjects adhere to a low fat diet theday of sample collection.

With the exception of post-dose assessments, visit-specificsubject-reported outcomes assessments were conducted or completed beforeany tests, procedures, or other consultations for that clinic visit toprevent influencing subject perceptions. A recommended order of studyprocedures was provided. Actual dates and times of assessments wererecorded in the source documentation and eCRF.

The approximate total blood volume to be collected from each subject was123.5 mL (See Table 12, below). Repeat or unscheduled samples could betaken for safety reasons or for technical issues with the samples.Additional serum or urine pregnancy tests could be performed, asdetermined necessary by the investigator or required by localregulation, to establish the absence of pregnancy at any time during thesubject's participation in the study.

TABLE 12 Volume of Blood to Be Collected From Each Subject No. of TotalVolume per Samples Volume of Type of Sample Sample (mL) per SubjectBlood (mL)^(a) Screening/Prospective Observational Phase Serum chemistry^(b) 5 1 5 TSH 3.5 1 3.5 Hematology ^(c) 2 1 2 Biomarker: protein ^(d)13 1 13 Biomarker: DNA 8.5 1 8.5 Biomarker: RNA 2.5 1 2.5 Double-blindInduction Phase Serum chemistry 2.5 2 5 Hematology 2 2 4Pharmacokinetics 2 4 8 Biomarker: protein (at 13 2 26 Visits 2.1 and2.9) ^(d) Biomarker: protein (at 10 1 10 Visit 2.4) Biomarker: DNA 8.5 18.5 Biomarker: RNA 2.5 3 7.5 Follow-up Phase Serum chemistry 2.5 1 2.5Hematology 2 1 2 Biomarker: protein ^(d) 13 1 13 Biomarker: RNA 2.5 12.5 Approximate volume of blood 123.5 mL collected during the study:^(a)Calculated as number of samples multiplied by amount of blood persample. ^(b) Serum chemistry includes serum β-hCG pregnancy tests (forwomen of childbearing potential) and lipid panel. ^(c) As needed, HbA1cwill be measured from the sample collected for hematology. ^(d) Bloodvolume listed under protein biomarkers represents the combined volume ofseveral different collection tubes. An indwelling IV cannula may be usedfor blood sample collection. Repeat or unscheduled samples may be takenfor safety reasons or technical issues with the samples.

Screening/Prospective Observational Phase

Prior to conducting any study procedure, the investigator (or designatedstudy personnel) reviewed and explained the written ICF to each subject.After signing the ICF, subjects who were 18 (or older if the minimumlegal age of consent in the country in which the study is taking placeis >18) to 64 years of age (inclusive) were screened to determineeligibility for study participation.

Subjects had to meet DSM-5 diagnostic criteria for single-episode MDD(if single-episode MDD, the duration must be ≥2 years) or recurrent MDD,without psychotic features, based upon clinical assessment and confirmedby the MINI. In addition, at the start of the screening/prospectiveobservational phase, the subject must have had an IDS-C₃₀ total score≥34.

At the start of this phase, subjects must been nonresponse to ≥2 but ≤5oral antidepressant treatments in the current episode of depression,assessed using the MGH-ATRQ and confirmed by documented medical historyand pharmacy/prescription records. The subject was taking an oralantidepressant treatment with nonresponse at entry and continued thistreatment at the same dosage for the duration of this phase to confirmnonresponse prospectively. Antidepressant treatment adherence wasassessed using the PAQ. Missing 24 days of antidepressant medication inthe prior 2-week period was considered as inadequate adherence.

The subject's current major depressive episode and antidepressanttreatment response to antidepressant therapies used during the currentdepressive episode were confirmed using the Site IndependentQualification Assessment.

An independent, blinded rater performed remote MADRS assessments toassess depressive symptoms during this phase. The investigator and studysite were blinded to specific details regarding the response criteriafor entry into the double-blind induction phase. Eligible non-responders(determined by remote blinded rater) discontinued their currentantidepressant medication(s) and any other prohibited psychotropicmedications, including adjunctive atypical antipsychotics.Benzodiazepines or nonbenzodiazepine sleep medications were allowed tocontinue but had specific restrictions regarding the administration timerelative to the intranasal treatment sessions.

All other subjects who did not proceed to the double-blind inductionphase ended study participation at this time. No further study visits orfollow-up were required.

Optional Antidepressant Taper Period

Since all nonresponder subjects were starting a new oral antidepressantduring the double-blind induction phase, no washout or drug-free periodwas required after discontinuing the current antidepressant treatment.However, an additional, optional period of up to 3 weeks was permittedto taper and discontinue the current oral antidepressant medication perthe local prescribing information or clinical judgment.

The taper period did not start until after the completion of 4 weeks ofprospective antidepressant treatment and assessment of theantidepressant treatment response.

Double-Blind Induction Phase

During this phase, subjects self-administered double-blind intranasaltreatment with esketamine (56 mg or 84 mg) or placebo twice per week for4 weeks as a flexible dose regimen. In addition, subjects simultaneouslyinitiated a new, open-label oral antidepressant.

Study subjects (with TRD) were randomly assigned to 1 of the following 2double-blind treatment groups at a 1:1 ratio (approximately 98 subjectsper group): 1. Intranasal placebo or 2. Intranasal esketamine (56 mg or84 mg). On the same day (i.e., Day 1), subjects were switched to a new,open-label oral antidepressant treatment. The oral antidepressant was 1of 4 oral antidepressant medications (duloxetine, escitalopram,sertraline, or venlafaxine XR). The antidepressant medication wasassigned by the investigator (based on review of the MGH-ATRQ andrelevant prior antidepressant treatment information) and was one thatthe subject had not previously had a nonresponse to in the currentdepressive episode, had not been previously intolerant to (lifetime),and was available in the participating country. Dosing of the oralantidepressant began on Day 1 and followed the local prescribinginformation for the respective product, with a forced titration to themaximally tolerated dose. The titration schedule for the selected oralantidepressant was as presented in Table 5, above.

For information obtained via telephone contact, written documentation ofthe communication was made available for review in the source documents.During telephone contact visits with the subject by site personnel,adverse event and concomitant therapy information were obtained. Inaddition, specified clinician-administered assessments were performed byappropriately qualified staff.

At the end of the double-blind induction phase, subjects who wereresponders (defined as ≥50% reduction in the MADRS total score frombaseline [Day 1 pre-randomization] to the end of the 4-week double-blindinduction phase) were eligible to enter the subsequent maintenanceclinical study (Study ESKETINTRD3003). To maintain study blinding, allresponder subjects, including responders to the active comparator (i.e.,oral antidepressant plus intranasal placebo), were eligible to enterStudy ESKETINTRD3003. Participation in ESKETINTRD3003 began immediatelyafter the completion of the double-blind induction phase. Subjectsreceived oral antidepressant medication and were instructed to continuetaking their oral antidepressant medication through their next studyvisit (i.e., first study visit of the stabilization phase in StudyESKETINTRD3003).

Those subjects who did not enter Study ESKETINTRD3003 proceeded into thefollow-up phase.

Early Withdrawal

If a subject withdrew before the end of the double-blind induction phasefor reasons other than withdrawal of consent, the Early Withdrawal visitwas conducted within 1 week of the date of discontinuation, followed bythe follow up phase. If the Early Withdrawal visit occurred on the sameday as a scheduled visit, the early withdrawal visit was performed onthe same day and duplicate assessments were not required.

Further clinical/standard of care for the treatment of depression werearranged by the study investigator and/or the subject's treatingphysician. The study investigator and/or treating physician determinedwhether or not the current oral antidepressant medication wouldcontinue.

If applicable, subjects who withdrew early received additional oralantidepressant medication and it was recommended that they continuetaking the oral antidepressant medication for at least the first 2 weeksof the follow-up phase unless determined as not clinically appropriate.

Follow-up Phase

All subjects who received at least 1 dose of intranasal study medicationin the double-blind induction phase and were not participating in thesubsequent ESKETINTRD3003 study proceeded into the 24-week follow-upphase. Clinic visits and remote assessment visits were performed asspecified in the Time and Events Schedule. During this phase, safety andtolerability, including potential withdrawal symptoms, followingdiscontinuation of intranasal esketamine were assessed. In addition,data was collected to assess the course of the subject's current majordepressive episode over a 6-month period.

Further clinical/standard of care for the treatment of depression werearranged by the study investigator and/or the subject's treatingphysician. No intranasal study medication was administered during thisphase. In order to better assess potential withdrawal symptoms from theintranasal medication it was recommended that the oral antidepressantmedication be continued for at least the first 2 weeks of the follow upphase unless determined as not clinically appropriate. The decision tocontinue the antidepressant was at the discretion of the investigator.

If information was obtained via telephone contact, written documentationof the communication was to be available for review in the sourcedocuments.

Any clinically significant abnormalities persisting at the end of thestudy were followed by the investigator until resolution or until aclinically stable endpoint was reached. All adverse events and specialreporting situations, whether serious or non-serious, were reporteduntil completion of the subject's last study-related procedure.

Efficacy Evaluations

It was recommended that the various subject-reported outcome assessmentsbe completed prior to other procedures.

Primary Efficacy Evaluation

The primary efficacy evaluation was the MADRS total score. The MADRS wasperformed by independent remote raters during the study. The 10-itemclinician-administered, clinician-rated scale MADRS was designed to beused in subjects with MDD to measure the overall severity of depressivesymptoms, including depression severity and to detect changes due toantidepressant treatment. The MADRS scale was used as the primaryefficacy measure for this study because it is validated, reliable, andacceptable to regulatory health authorities as a primary scale todetermine efficacy in major depression.

The MADRS scale consists of 10 items, each of which is scored from 0(item not present or normal) to 6 (severe or continuous presence of thesymptoms), for a total possible score of 60. Higher scores represent amore severe condition. The MADRS evaluates apparent sadness, reportedsadness, inner tension, sleep, appetite, concentration, lassitude,interest level, pessimistic thoughts, and suicidal thoughts. The testexhibits high inter-rater reliability.

The primary efficacy endpoint was a change in the MADRS total score frombaseline (Day 1 prior to randomization) to the end of the 4-weekdouble-blind induction phase.

In this study, subjects in any of the 2 treatment groups who respondedto the study medication (i.e., responders) were defined as subjects whomet the criterion for response defined as 250% reduction in the MADRStotal score from baseline (Day 1 pre-randomization) to the end of the4-week double-blind induction phase.

In addition to being the primary efficacy measure, the MADRS was alsoused to evaluate the key secondary efficacy endpoint of onset ofclinical response (i.e., antidepressant effect) by Day 2 that wasmaintained for the duration of the double-blind induction phase. Onsetof clinical response was defined as ≥50% improvement in MADRS totalscore by Day 2 (i.e., the day after taking the first dose ofdouble-blind intranasal medication) that continued through the end ofthe double-blind phase.

MADRS was also used to evaluate a secondary objective assessingproportion of subjects with response and those in remission (defined assubjects with a MADRS total score ≤12) at the end of the 4-weekdouble-blind induction phase.

Key Secondary Efficacy Evaluation (Clinician-Completed)

The MADRS was administered using a modified recall period of 24 hoursfor the key secondary efficacy evaluation related to onset of clinicalresponse by Day 2 that was maintained for the duration of thedouble-blind induction phase.

The MADRS with a 24-hour recall period was used on Day 2. Thefeasibility of this shortened recall period has been confirmed withpatients, and physicians, and there are data supporting the psychometricproperties of this shortened recall period. The MADRS with a 7-dayrecall was used for all subsequent MADRS assessments used for the keysecondary efficacy evaluation (maintenance of clinical response achievedon Day 2 for duration of double-blind induction phase).

Key Secondary Efficacy Evaluation (Patient-Reported Outcome)

The Patient Health Questionnaire (PHQ-9) is a 9-item, subject-reportedoutcome measure that was used to assess depressive symptoms. The scalescores each of the 9 symptom domains of the DSM-5 MDD criteria and hasbeen used both as a screening tool and a measure of response totreatment for depression. Each item was rated on a 4-point scale (0=notat all, 1=several days, 2=more than half the days, and 3=nearly everyday). The subject's item responses were summed to provide a total score(range of 0 to 27) with higher scores indicating greater severity ofdepressive symptoms. The recall period was 2 weeks.

The Sheehan Disability Scale (SDS) was used to assess the secondaryobjective of functional impact and associated disability. The SDS is asubject-reported outcome measure and is a 5-item questionnaire which hasbeen widely used and accepted for assessment of functional impairmentand associated disability. The first three items assess disruption of(1) work/school, (2) social life, and (3) family life/homeresponsibilities using a 0-10 rating scale. The score for the firstthree items were summed to create a total score of 0-30 where a higherscore indicated greater impairment. The SDS also has one item on dayslost from school or work and one item on days when underproductive. Therecall period for this study was 7 days.

The Clinical Global Impression-Severity (CGI-S) provides an overallclinician-determined summary measure of the severity of the subject'sillness that takes into account all available information, includingknowledge of the subject's history, psychosocial circumstances,symptoms, behavior, and the impact of the symptoms on the subject'sability to function. The CGI-S evaluates the severity of psychopathologyon a scale of 0 to 7. Considering total clinical experience, a subjectwas assessed on severity of mental illness at the time of ratingaccording to: 0=not assessed; 1=normal (not at all ill); 2=borderlinementally ill; 3=mildly ill; 4=moderately ill; 5=markedly ill; 6=severelyill; 7=among the most extremely ill patients. The CGI-S permits a globalevaluation of the subject's condition at a given time.

The 7-item subject-reported Generalized Anxiety Disorder 7-item Scale(GAD-7) was used to measure the secondary objective of symptoms ofanxiety. The GAD-7 is a brief and validated measure of overall anxiety.Each item was rated on a 4-point scale (0=not at all; 1=several days;2=more than half the days; and 3=nearly every day). Item responses weresummed to yield a total score with range of 0 to 21, where higher scoresindicated more anxiety. The recall period was 2 weeks.

The Euro-Qol-5 Dimention-5 Level (EQ-5D-5L) is a standardized instrumentfor use as a measure of health outcome, primarily designed forself-completion by respondents. It consists of the EQ-5D-5L descriptivesystem and the EQ visual analogue scale (EQ-VAS). The EQ-5D-5Ldescriptive system comprises the following 5 dimensions: Mobility,self-care, usual activities, pain/discomfort and anxiety/depression.Each of the 5 dimensions is divided into 5 levels of perceived problems(Level 1 indicating no problem, Level 2 indicating slight problems,Level 3 indicating moderate problems, Level 4 indicating severeproblems, and Level 5 indicating extreme problems).

The subject selected an answer for each of the 5 dimensions consideringthe response that best matches his or her health “today.” Thedescriptive system was used to represent a health state. The EQ-VASself-rating recorded the respondent's own assessment of his or heroverall health status at the time of completion, on a scale of 0 to 100.

Primary Endpoint

The primary efficacy endpoint was the change in the MADRS total score asmeasured by the change from baseline (Day 1 prior to randomization) tothe end of the 4-week double-blind induction phase.

Primary Endpoint Results:

A serial gatekeeping (fixed sequence) approach was applied to adjust formultiplicity and to strongly control type I error across the primary andthe 3 key secondary efficacy endpoints (onset of clinical response,change in SDS total score, and change in PHQ-9 total score). The 3 keysecondary endpoints were analyzed sequentially and were consideredstatistically significant at the 1-sided 0.025 level only if theendpoint was individually significant at the 1-sided 0.025 level andprevious endpoints in the hierarchy were significant at the 1-sided0.025 level, including the primary endpoint. If the primary endpoint wasstatistically significant, the selected secondary endpoints wereassessed in the following order: onset of clinical response, change inSDS total score, change in PHQ-9 total score.

The primary efficacy endpoint was the change in MADRS total score frombaseline to Day 28. MADRS total scores range from 0 to 60. The primaryefficacy analysis was performed on the full analysis set, which includedall randomized subjects who received at least 1 dose of intranasal studymedication and 1 dose of oral antidepressant study medication. As shownin Table 13 below, results for the change in MADRS total score favoredintranasal esketamine+oral AD over oral AD+ intranasal placebo. (FIG. 2presents the least-square mean changes (±SE) from baseline for the MADRStotal score over time in the double-blind phase based on the MMRManalysis.) The mean change from baseline (SD) at Day 28 was −21.4(12.32) for esketamine+oral AD and −17.0 (13.88) for the activecomparator. Based on an MMRM model with treatment, day, country, classof oral antidepressant and treatment by day as factors and baselinevalue as a covariate, the least-square mean difference (SE) betweenesketamine+oral AD and active comparator was −4.0 (1.69). The differencebetween treatment groups was statistically significant (one-sidedp=0.010). The MMRM analysis was considered the primary analysis for alldossiers except the EU.

Results based on an ANCOVA model for the change in MADRS total scorefrom baseline to End Point (DB) with factors for treatment, country andclass of oral antidepressant and baseline value as a covariate wereconsistent with the MMRM analysis (least-square mean difference (SE)between esketamine+oral AD and active comparator was −3.5 (1.63),one-sided p=0.017.

TABLE 13 Montgomery-Asberg Depression Rating Scale (MADRS) Total Score:Change From Baseline to Day 28 MMRM; Double-blind Induction Phase (StudyESKETINTRD3002: Full Analysis Set) Oral AD + Intranasal Esk + IntranasalPlacebo Oral AD (N = 114) (N = 109) Baseline N 114 109 Mean (SD) 37.0(5.69) 37.3 (5.66) Median (Range) 37.0 (22; 48) 37.0 (21; 52) Day 28 N101 100 Mean (SD) 15.5 (10.67) 20.6 (12.70) Median (Range) 12.0 (1; 49)19.0 (0; 49) Change from baseline to day 28 N 101 100 Mean (SD) −21.4(12.32) −17.0 (13.88) Median (Range) −24.0 (−44; 13) −18.5 (−43; 8) MMRManalysis ^(a) Diff. of LS means (SE) −4.0 (1.69) (Esk + AD minus AD +Placebo) 95% confidence interval on diff. −7.31; −0.64 1-sided p-value    0.010 ^(a) Test for treatment effect is based on mixed model forrepeated measures (MMRM) with change from baseline as the responsevariable and the fixed effect model terms for treatment (intranasalesk + oral AD, oral AD + intranasal placebo), day, country, class oforal antidepressant (SNRI or SSRI), and treatment-by-day, and baselinevalue as a covariate. A negative difference favors esketamine. MADRSTotal score ranges from 0 to 60; a higher score indicates a more severecondition. Negative change in score indicates improvement.

Secondary Endpoints

The first key secondary endpoint was the change from baseline (Day 1prior to randomization) to the end of the 4-week double-blind inductionphase in subject-reported depressive symptoms, using the PHQ-9 totalscore.

The second key secondary endpoint was the proportion of subjects showingonset of clinical response by Day 2 that was maintained through the endof the 4-week double-blind induction phase. Onset of clinical responsewas defined as 250% reduction in the MADRS total score by the day aftertaking the first dose of double-blind medication [Day 2] that continuedthrough the end of the 4-week double-blind induction phase). Subjectswho discontinued the study prior to the end of the double-blindinduction phase were not considered to have maintained clinicalresponse.

The third key secondary endpoint was the change in SDS total score asmeasured by the change from baseline (Day 1 prior to randomization) tothe end of the 4-week double-blind induction phase.

Other secondary efficacy endpoints included: (a) Proportion ofresponders (≥50% reduction from baseline in MADRS total score) at theend of the 4-week double-blind induction phase, (b) Proportion ofsubjects in remission (MADRS≤12) at the end of the 4-week double-blindinduction phase, and (c) Change from baseline (Day 1 prior torandomization) to the end of the 4-week double-blind induction phase in:Severity of depressive illness, using the CGI-S, Anxiety symptoms, asmeasured by the GAD-7, Health-related quality of life and health status,as assessed by the EQ-5D-5L.

Secondary Endpoint Results Onset of Clinical Response

A subject was defined as having a clinical response if there was atleast 50% improvement from baseline in the MADRS total score with onsetby Day 2 that was maintained to Day 28 at each visit. Subjects wereallowed one excursion (non-response) on Days 8, 15 or 22, however thescore must have shown at least 25% improvement. Subjects who do not meetsuch criterion, or discontinue during the study before Day 28 for anyreason were considered as non-responders and were assigned the value ofno, meaning they did not meet the criteria for Onset of ClinicalResponse.

As shown in Table 14 below, 7.9% of subjects in the esketamine+oral ADgroup achieved clinical response compared to 4.6% of subjects in theactive comparator group. The difference between treatment groups was notstatistically significant at the 1-sided 0.025 level. Hence, based onthe predefined testing sequence of key secondary endpoints, SDS totalscore and PHQ-9 total score could not be formally evaluated.

TABLE 14 Onset of Clinical Response Based on Montgomery-AsbergDepression Rating Scale (MADRS) Total Score CMH Analysis; Double-blindInduction Phase (Study ESKETINTRD3002: Full Analysis Set) Oral AD +Intranasal Esk + Intranasal Placebo Oral AD (N = 114) (N = 109) Onset ofclinical response, n (%) ^(a) N 114 109 Yes 9 (7.9%)  5 (4.6%) No 105(92.1%) 104 (95.4%) Generalized Cochran-Mantel- Haenszel test ^(b)1-sided p-value (esk + AD vs. 0.161 AD + placebo) ^(c) Odds ratio (95%CI) ^(d) 1.79 (0.57, 5.67) ^(a) Onset of clinical response was definedas at least 50% improvement from baseline in MADRS total score withonset by Day 2 that is maintained to Day 28. Subjects are allowed oneexcursion (non-response) on Days 8, 15 or 22, provided the score is atleast 25% improvement. Subjects with missed assessments or discontinuedearly were not considered to have onset of clinical response. ^(b)Generalized Cochran-Mantel-Haenszel (CMH) test for mean score differencebetween treatments adjusting for country and class of oralantidepressant (SNRI or SSRI). ^(c) The analysis was consideredstatistically significant at the 1-sided 0.025 level only if the MADRStotal score analysis is also significant. ^(d) Odds of achieving onsetof clinical response on intranasal esketamine + oral AD divided by theodds of achieving onset of clinical response on oral AD + intranasalplacebo.

Response and Remission Rates Based on MADRS Total Score

Response (≥50% improvement from baseline in the MADRS total score) andRemission (MADRS total score is ≤12) rates were as presented in Table 15and FIGS. 3-5.

TABLE 15 Response and Remission Rates Based on Montgomery-AsbergDepression Rating Scale (MADRS); Double-blind Induction Phase (StudyESKETINTRD3002: Full Analysis Set) Response Remission Intranasal OralAD + Intranasal Oral AD + Esk + Intranasal Esk + Intranasal Oral ADPlacebo Oral AD Placebo Day 2 (24 hrs.) 18/109 (16.5%) 11/102 (10.8%)10/109 (9.2%)  6/102 (5.9%) Day 8 15/109 (13.8%) 13/105 (12.4%) 8/109(7.3%) 7/105 (6.7%) Day 15 29/107 (27.1%) 23/102 (22.5%) 13/107 (12.1%)13/102 (12.7%) Day 22 54/103 (52.4%) 35/104 (33.7%) 32/103 (31.1%)20/104 (19.2%) Day 28 70/101 (69.3%) 52/100 (52.0%) 53/101 (52.5%)31/100 (31.0%) A subject was defined as a responder at a given timepoint if the percent improvement from baseline in MADRS total score wasat least 50%. A subject was in remission at a given time point if theMADRS total score was ≤12.

Sheehan Disability Scale (SDS)

The SDS is a subject-reported outcome measure and is a 5-itemquestionnaire which has been widely used and accepted for assessment offunctional impairment and associated disability. The first three itemsassess disruption of (1) work/school, (2) social life, and (3) familylife/home responsibilities using a 0-10 rating scale. The score for thefirst three items are summed to create a total score of 0-30 where ahigher score indicates greater impairment.

As shown in Table 16 below, results for the change in SDS total scorefavored intranasal esketamine+oral AD over oral AD+ intranasal placebo.The mean change from baseline (SD) at Day 28 was −13.3 (8.22) foresketamine+oral AD and −9.5 (8.38) for the active comparator. Based onan MMRM model with treatment, day, country, class of oral antidepressantand treatment by day as factors and baseline value as a covariate, theleast-square mean difference (SE) between esketamine+oral AD and activecomparator was −3.6(1.18). Based on the pre-defined testing sequence ofkey secondary endpoints, SDS total score could not be formally evaluatedbecause there was not a statistically significant difference betweentreatment groups for onset of clinical response. The nominal one-sidedp-value=0.001.

Results based on an ANCOVA model for the change in SDS total score frombaseline to End Point (DB) with factors for treatment, country and classof oral antidepressant and baseline value as a covariate were consistentwith the MMRM analysis.

TABLE 16 Sheehan Disability Scale (SDS) Total Score: Change FromBaseline to Day 28 MMRM; Double-blind Induction Phase (StudyESKETINTRD3002: Full Analysis Set) Oral AD + Intranasal Esk + IntranasalPlacebo Oral AD (N = 114) (N = 109) Baseline N 111  104  Mean (SD) 24.0(4.07) 24.2 (4.38) Median (Range) 25.0 (11; 30) 25.0 (11; 30) Day 28 N84 85 Mean (SD) 10.3 (7.73) 14.6 (9.06) Median (Range) 9.0 (0; 29) 15.0(0; 30) Change from baseline to day 28 N 84 84 Mean (SD) −13.3 (8.22)−9.5 (8.38) Median (Range) −14.0 (−30; 6) −9.5 (−29; 6) MMRM analysis^(a) Diff. of LS means (SE) (Esk + −3.6 (1.18) AD minus AD + Placebo)95% confidence interval on diff. −5.94; −1.27 1-sided p-value ^(b)   0.001 ^(a) Test for treatment effect was based on mixed model forrepeated measures (MMRM) with change from baseline as the responsevariable and the fixed effect model terms for treatment (intranasalesketamine + oral AD, oral AD + intranasal placebo), day, country, classof oral antidepressant (SNRI or SSRI), and treatment-by-day, andbaseline value as a covariate. A negative difference favored esketamine.^(b) The analysis was considered statistically significant at the1-sided 0.025 level only if the MADRS total score and the onset ofclinical response analyses are also significant. Negative change in SDSscore indicates improvement.

Patient Health Questionnaire-9 Item (PHQ-9)

The PHQ-9 is a 9-item, self-report scale assessing depressive symptoms.Each item is rated on a 4-point scale (0=Not at all, 1=Several Days,2=More than half the days, and 3=Nearly every day), with a total scorerange of 0-27. A higher score indicates greater severity of depression.

As shown in Table 17 below, results for the change in PHQ-9 total scorefavored intranasal esketamine+oral AD over oral AD+ intranasal placebo.The mean change from baseline (SD) at Day 28 was −12.8 (6.43) foresketamine+oral AD and −10.2(7.84) for the active comparator. Based onan MMRM model with treatment, day, country, class of oral antidepressantand treatment by day as factors and baseline value as a covariate, theleast-square mean difference (SE) between esketamine+oral AD and activecomparator was −2.2(0.89). Based on the predefined testing sequence ofkey secondary endpoints, PHQ-9 total score cannot be formally evaluatedbecause there was not a statistically significant difference betweentreatment groups for onset of clinical response. The nominal one-sidedp-value=0.006.

Results based on an ANCOVA model for the change in PHQ-9 total scorefrom baseline to End Point (DB) with factors for treatment, country andclass of oral antidepressant and baseline value as a covariate wereconsistent with the MMRM analysis (see Attachment 3).

TABLE 17 Patient Health Questionnaire (PHQ-9) Total Score: Change FromBaseline to Day 28 MMRM Double-blind Induction Phase (StudyESKETINTRD3002: Full Analysis Set) Oral AD + Intranasal Esk + IntranasalPlacebo Oral AD (N = 114) (N = 109) Baseline N 114 109  Mean (SD) 20.2(3.63) 20.4 (3.74) Median (Range) 20.0 (5; 27) 21.0 (10; 27) Day 28 N101 99 Mean (SD) 7.4 (5.76) 10.1 (7.71) Median (Range) 6.0 (0; 27) 8.0(0; 26) Change from baseline to day 28 N 101 99 Mean (SD) −12.8 (6.43)−10.2 (7.84) Median (Range) −14.0 (−26; 3) −9.0 (−25; 6) MMRM analysis^(a) Diff. of LS means (SE) (Esk + −2.2 (0.89) AD minus AD + Placebo)95% confidence interval on diff. −3.99; −0.48 1-sided D-value ^(b)    0.006 ^(a) Test for treatment effect was based on mixed modelrepeated measures (MMRM) with change from baseline as the responsevariable and the fixed effect model terms for treatment (intranasalesketamine + oral AD, oral AD + intranasal placebo), day, country, classof oral antidepressant (SNRI or SSRI), and treatment-by-day, andbaseline value as a covariate. A negative difference favored esketamine.^(b) The analysis was considered statistically significant at the1-sided 0.025 level only if the MADRS total score, onset of clinicalresponse, and SDS total score analyses are also significant. Negativechange in PHQ-9 score indicates improvement.

Safety Evaluations

Any clinically relevant changes occurring during the study were recordedon the Adverse Event section of the eCRF. Any clinically significantabnormalities persisting at the end of the study/early withdrawal werefollowed by the investigator until resolution or until a clinicallystable endpoint was reached. The study included the followingevaluations of safety and tolerability according to the time pointsprovided in the Time and Events Schedule.

Adverse Events

Adverse events were reported by the subject (or, when appropriate, by acaregiver, surrogate, or the subject's legally acceptablerepresentative) for the duration of the study. Adverse events werefollowed by the investigator. TEAEs of special interest were examinedseparately.

Clinical Laboratory Tests

Blood samples for serum chemistry and hematology and a urine sample forurinalysis were collected. The investigator reviewed the laboratoryreport, documented this review, and recorded any clinically relevantchanges occurring during the study in the adverse event section of theeCRF. The laboratory reports were filed with the source documents. Theuse of local laboratories was allowed in cases where initiation oftreatment or safety follow-up was time-critical and the centrallaboratory results were not expected to be available before the need tobegin dosing or if actions need to be taken for safety reasons.

The following tests were performed by the central laboratory, unlessnoted otherwise:

Hematology Panel hemoglobin platelet count hematocrit red blood cell(RBC) count white blood cell (WBC) count with differential

Serum Chemistry Panel sodium alkaline phosphatase potassium creatinephosphokinase (CPK) chloride calcium bicarbonate phosphate blood ureanitrogen (BUN) albumin creatinine total protein glucose aspartateaminotransferase (AST) alanine aminotransferase (ALT)gamma-glutamyltransferase (GGT)

Urinalysis Dipstick Sediment (if dipstick result is abnormal) specificgravity red blood cells pH white blood cells glucose epithelial cellsprotein crystals blood casts ketones bacteria bilirubin urobilinogennitrite leukocyte esterase If dipstick result was abnormal, flowcytometry or microscopy was used to measure sediment. In case ofdiscordance between the dipstick results and the flow cytometricresults, the sediment was examined microscopically.

The following tests were done at time points specified in the Time andEvents Schedule:

-   -   1. Lipid panel: Total cholesterol, low density lipoprotein        (LDL)-cholesterol, low density lipoprotein (HDL)-cholesterol,        and triglycerides    -   2. Serum and urine pregnancy testing (for women of childbearing        potential only)    -   3. Urine Drug Screen: Barbiturates, methadone, opiates, cocaine,        cannabinoids (cannabinoids are only tested at Day 1 predose),        phencyclidine, and amphetamine/methamphetamine    -   4. Alcohol breath test    -   5. Thyroid-stimulating hormone (TSH)    -   6. Glycated hemoglobin (HbA1c) test    -   7. A serum follicle stimulating hormone (FSH) level test, only        if required for documentation that a female subject is not of        childbearing potential (refer to Inclusion Criteria No. 0)

Single, 12-Lead ECG

During the collection of ECGs, subjects should be in a quiet settingwithout distractions (e.g., television, cell phones). Subjects shouldrest in a supine position for at least 5 minutes before ECG collectionand should refrain from talking or moving arms or legs.

All ECG tracings were sent to a central ECG laboratory. The ECGs wereread at the scheduled time points and summarized by a central ECGlaboratory. The investigator or sub-investigator was required to reviewall ECGs at the study visit to assess for any potential safety concernsor evidence of exclusionary conditions.

Vital Signs (Temperature, Pulse/Heart Rate, Respiratory Rate, BloodPressure)

Blood pressure and pulse/heart rate measurements were assessed supinewith a completely automated device. Manual techniques were used only ifan automated device is not available. Blood pressure and pulse/heartrate measurements were preceded by at least 5 minutes of rest in a quietsetting without distractions (e.g., television, cell phones).

Tympanic temperature was recommended. An automated device was used formeasurement of respiratory rate.

Pulse Oximetry

Pulse oximetry was used to measure arterial oxygen saturation. On eachdosing day, the device was attached to the finger, toe, or ear beforethe first nasal spray and then, after the first spray it was monitoredand documented. Any arterial blood oxygen saturation (SpO₂)<93% andlasting for more than 2 minutes, and confirmed by an additional manualmeasurement on another part of the body, was reported as an adverseevent.

On intranasal treatment session days, pulse oximetry was performed every15 minutes from pre-dose to t=1.5 hours post-dose. If s93% at any timeduring the 1.5 hours post-dose interval, pulse oximetry was performedevery 5 minutes until returned to 293% or until the subject was referredfor appropriate medical care, if clinically indicated.

Physical Examination, Height, Body Weight, and Neck Circumference

Physical examinations, body weight, and height were performed ormeasured as per the Time and Events Schedule. In addition, body massindex (BMI) was calculated and neck circumference measured as part ofthe information required for the STOP-Bang questionnaire.

Nasal Examinations

Nasal examinations (including the upper respiratory tract/throat) wereconducted by a qualified healthcare practitioner. The objective of theexamination at screening was to rule out any subjects with anatomical ormedical conditions that may impede drug delivery or absorption.

Subsequent examinations consisted of a visual inspection of thenostrils, nasal mucosa, and throat for nasal erythema, rhinorrhea,rhinitis, capillary/blood vessel disruption, and epistaxis, and weregraded as absent, mild, moderate, or severe. Any treatment-emergentchange or worsening from the baseline examination was recorded as anadverse event.

Nasal Symptom Questionnaire

Subjects completed a nasal symptom questionnaire. The nasal symptomquestionnaire was developed to assess nasal tolerability followingintranasal administration of study drug. The questionnaire asks aboutnasal symptoms, which were rated by the subject as none, mild, moderate,or severe, based on how he or she feels at the time of the assessment.

C-SSRS

The C-SSRS was performed to assess potential suicidal ideation andbehavior. The C-SSRS is a low-burden measure of the spectrum of suicidalideation and behavior that was developed in the National Institute ofMental Health Treatment of Adolescent Suicide Attempters Study to assessseverity and track suicidal events through any treatment. It is aclinical interview providing a summary of both suicidal ideation andbehavior that can be administered during any evaluation or riskassessment to identify the level and type of suicidality present. TheC-SSRS can also be used during treatment to monitor for clinicalworsening.

Two versions of the C-SSRS were used in this study, theBaseline/Screening version, and the Since Last Visit version. TheBaseline/Screening version of the C-SSRS was used in thescreening/prospective observational phase. In this version, suicidalideation was assessed at 2 time points (“lifetime” and “in the past 6months”) and suicidal behavior was assessed at 2 time points (“lifetime”and “in the past year”). All subsequent C-SSRS assessments in this studyused the Since Last Visit version, which assessed suicidal ideation andbehavior since the subject's last visit.

CADSS

The CADSS is an instrument for the measurement of present-statedissociative symptoms, and was administered to assess treatment-emergentdissociative symptoms. The CADSS consists of 23 subjective items,divided into 3 components: Depersonalization (Items 3 to 7, 20, and 23),derealization (Items 1, 2, 8 to 13, 16 to 19, and 21) and amnesia (Items14, 15, and 22). Participant's responses were coded on a 5-point scale(0=not at all through to 4=extremely). CADSS has excellent inter-raterreliability and internal consistency.

BPR+

Four items of the BPRS were administered to assess potentialtreatment-emergent psychotic symptoms. The BPRS is an 18-item ratingscale that is used to assess a range of psychotic and affectivesymptoms, rated from both observation of the subject and the subject'sown report. It reportedly provides a rapid and efficient evaluation oftreatment response in clinic drug studies and in clinical settings. Onlythe 4-item positive symptom subscale BPRS+(i.e., suspiciousness,hallucinations, unusual thought content, and conceptual disorganization)were used in this study. It is highly sensitive to change, and excellentinter-rater reliability can be achieved with training and a standardinterview procedure.

MQAA/S

The MOAA/S was used to measure treatment-emergent sedation, withcorrelation to levels of sedation defined by the American Society ofAnesthesiologists (ASA) continuum. The MOAA/S scores range from 0=noresponse to painful stimulus (corresponds to ASA continuum for generalanesthesia) to 5=readily responds to name spoken in normal tone (awake;corresponds to ASA continuum for minimal sedation).

On each intranasal dosing day, the MOAA/S was performed every 15 minutesfrom pre-dose to t=+1.5 hours post-dose. If the score was ≤3 at any timeduring the 1.5 hours post-dose interval, the MOAA/S was performed every5 minutes until a score of 4 is reached (at which point a frequency ofevery 15 minutes can be resumed until t=+1.5 hours post dose). If asubject did not have a score of at least 5 at t=+1.5 hours post-dose,they were monitored further. For subjects with a score of 4, theassessment was repeated every 15 minutes. And for subjects with a scoreof ≤3, the assessment was repeated every 5 minutes until the scorereturns to 5 or the subject was referred for appropriate medical care,if clinically indicated.

CGADR

The CGADR was used to measure the subject's current clinical status andwas the clinician's assessment of the readiness to be discharged fromthe study site. The clinician answered “Yes” or “No” to the question “Isthe subject considered ready to be discharged based on their overallclinical status (e.g., sedation, blood pressure, and other adverseevents)?”

On each intranasal dosing day, the CGADR was performed at 1 hour and 1.5hours post-dose; if the response was not “Yes” at 1.5 hours post-dose,the assessment was repeated every 15 minutes until a “Yes” response wasachieved or until the subject was referred for appropriate medical care,if clinically indicated. A subject was not discharged prior to the1.5-hour time point. On all intranasal treatment session days, subjectsremained at the clinical site until study procedures were completed andthe subject was ready for discharge.

PWC-20

The PWC-20 was administered to assess potential withdrawal symptomsfollowing cessation of intranasal esketamine treatment. An assessmentwas performed on Day 25 to establish a baseline prior to discontinuationof intranasal esketamine treatment. In order to better assess potentialwithdrawal symptoms from the intranasal medication it was recommendedthat the oral antidepressant medication be continued for at least thefirst 2 weeks of the follow up phase unless determined as not clinicallyappropriate.

The PWC-20 is a 20-item simple and accurate method to assess potentialdevelopment of discontinuation symptoms after stopping of study drug.The PWC-20 is a reliable and sensitive instrument for the assessment ofdiscontinuation symptoms. Discontinuation symptoms occur early anddisappear rather swiftly, depending upon speed of taper, dailymedication dose, and drug elimination half-life.

BPIC-SS

The BPIC-SS is a subject-reported outcome measure that was developed toidentify an appropriate bladder pain syndrome/interstitial cystitispopulation for clinical studies evaluating new treatments for bladderpain syndrome.

The BPIC-SS was used to monitor subjects for potential symptoms ofcystitis, bladder pain, and interstitial cystitis. The BPIC-SS includes8 questions with a recall period of the past 7 days, and addresses keysymptoms identified by subjects with BPS including symptom concepts ofpain and/or pressure of the bladder and urinary frequency. Subjectsresponded to items using a 5-point scale (0=never, 1=rarely,2=sometimes, 3=most of the time, 4=always for frequency-based questions,and 0=not at all, 1=a little, 2=somewhat, 3=moderately, and 4=a greatdeal for items related to bother associated with symptoms). Question 8records the worst bladder pain in the last 7 days using a 0-10 numericalrating scale. A total score was calculated by adding up the numbersbeside the response options chosen by the subject. The range of possiblescores for the scale is 0 to 38. A total score of 19 or moredemonstrated good sensitivity/specificity and was considered a relevantcut-off to distinguish those with significant bladder symptoms orcystitis.

If any items were missing, a total score could not be calculated.

In the current study, if a subject had a score >18 on the BPIC-SS scaleand there was no evidence of urinary tract infection based on urinalysisand microscopy, he or she was referred to a specialist for furtherevaluation. As such, in addition to urinalysis, a urine culture wasobtained if BPIC-SS score was >18 on applicable study day.

Cognition Testing: Computerized Cognitive Battery and HVLT-R

The computerized cognitive battery provides assessment of multiplecognitive domains, including attention, visual learning and memory, andexecutive function. The tests use culture-neutral stimuli, enabling usein multilingual/multicultural settings. The computerized batteryincludes:

Simple and choice reaction time tests; scored for speed of response(mean of the log 10-transformed reaction times for correct responses)

Visual episodic memory; visual recall test scored using arcsinetransformation of the proportion of correct responses

Working memory (n back); scored for speed of correct response (mean ofthe log 10-transformed reaction times for correct responses)

Executive function; maze/sequencing test, scored for total number oferrors

All measures have been validated against traditional neuropsychologicaltests and are sensitive to the effects of various drugs on cognitiveperformance, including alcohol and benzodiazepines. Completing thecognitive battery requires approximately 25 minutes.

The HVLT-R, a measure of verbal learning and memory, is a 12-item wordlist recall test. Administration includes 3 learning trials, a 24-wordrecognition list (including 12 target and 12 foil words), and a delayedrecall (20-minute) trial. Administration is computer-assisted;instructions and word lists appear on-screen. The test administratorrecords each word correctly recalled, and scores for learning,short-term, and delayed recall are generated via the test software. TheHVLT-R is a well-validated and widely used measure of verbal episodicmemory.

The tests were administered in the following order HVLT-R, computerizedcognitive test battery, and HVLT-R Delayed.

UPSIT and Smell Threshold Test

To assess any potential treatment-emergent effects on the sense ofsmell, olfactory function was qualitatively and quantitatively assessedusing validated standardized olfactory tests prior to and at specifiedtime points during the study. The 2 tests administered were:

The UPSIT assesses a subject's ability to identify odors. Thisstandardized test, the most widely used olfactory test in the world, isderived from basic psychological test measurement theory and focuses onthe comparative ability of subjects to identify odorants at thesuprathreshold level. The UPSIT consists of 4 envelope-sized booklets,each containing 10 “scratch and sniff” odorants embedded in 10- to 50-μmpolymer microcapsules positioned on brown strips at the bottom of thepages of the booklets. The internal consistency and test-retestreliability coefficients of this instrument are >0.90. Numerous studieshave shown this and related tests to be sensitive to subtle changes insmell function associated with multiple etiologies, including those dueto viruses, head trauma, and a number of neurodegenerative diseases.

The Smell Threshold Test assesses the smell threshold using aforced-choice single staircase threshold procedure. This test quantifiesa detection threshold for the rose-like smelling odorant phenyl ethylalcohol (PEA). This odorant is used because it has little propensity tostimulate the trigeminal nerve within the nose. This test is sensitiveto olfactory deficits from a wide range of disorders.

These tests were administered bilaterally (i.e., both nostrils at thesame time). Testing occurred during the screening/prospectiveobservational phase to establish a subject's baseline sensitivity. Thedegree of change from this baseline was determined subsequently overtime. The percent change from baseline served as the dependent measurefor each subject for each test.

MINI

Subjects underwent MINI (a brief, structured diagnostic interview) toconfirm the diagnosis of MDD and to determine if there are otherpsychiatric conditions present. It has an administration time ofapproximately 15 minutes.

MGH-ATRQ

The MGH-ATRQ was used to determine treatment resistance in MDD. TheMGH-ATRQ evaluates the adequacy of duration and dosage of allantidepressant medications used for the current major depressiveepisode. In addition, the MGH-ATRQ assesses the degree of improvement ona scale from 0% (not improved at all) to 100% (completely improved). TheMGH-ATRQ was completed by the clinician in collaboration with thesubject.

STOP-Bang Questionnaire

The STOP-Bang Questionnaire is a concise, easy-to-use, validated, andsensitive screening tool for obstructive sleep apnea (OSA). Thisquestionnaire has 8 items which address key risk factors for obstructivesleep apnea: snoring, tiredness, observed breathing interruption duringsleep, high blood pressure, body mass index, age, neck size, and gender.The STOP-Bang questions do not specify a recall period. Subjects answeryes or no to questions about snoring, tiredness, observed breathinginterruption, and high blood pressure (these are the “STOP” items in theSTOP-BANG acronym); this takes approximately 1 minute.

Study site staff answered yes or no to questions about body mass index(more than 35 kg/m²?), age (older than 50 years?), neck circumference(larger than 17 inches [43 cm] in men, or larger than 16 inches [41 cm]in women?), and gender (male?).

The total STOP-BANG score was calculated by summing the number ofpositive responses, yielding a score range of 0 to 8. A score of ≥5 onthe STOP-Bang indicates a moderate to severe risk for Obstructive SleepApnea (apnea hypopnea index of >30).

Site Independent Qualification Assessment

Independent psychiatrists/psychologists performed the Site IndependentQualification Assessment by telephone in the screening/prospectiveobservational phase for all subjects to confirm diagnosis of depressionand eligibility for the study.

IDS-C₃₀

The 30-item IDS-C₃₀ is designed to assess the severity of depressivesymptoms.

The IDS assesses all the criterion symptom domains designated by theDSM-5 to diagnose a major depressive episode. These assessments can beused to screen for depression, although they have been usedpredominantly as measures of symptom severity. The 7-day period prior toassessment is the usual time frame for assessing symptom severity. Thepsychometric properties of the IDS-Cao have been established in variousstudy samples.

Massachusetts General Hospital Female Reproductive Lifecycle andHormones Questionnaire (MGH-Female RLHQ): Module I and Menstrual CycleTracking

The MGH-Female RLHQ Module I (childbearing potential, menopausal status,and menstrual cycle) is a brief questionnaire aimed at standardizing theminimal collection of relevant information about reproductive hormonesand status. It was completed by a clinician. This information mayfacilitate exploratory analyses of the impact of endogenous andexogenous reproductive hormones on the course of treatment of MDD andpotentially inform care of women with MDD in the future.

Menstrual cycle tracking (start date of last menstrual period) wasdocumented at the study visits specified in the Time and EventsSchedule.

PAQ

Subjects' adherence to their oral antidepressant treatment regimenduring the screening/prospective observational phase was assessed usingthe PAQ. It is a brief, 2-item subject-report outcome measure that wasdeveloped at the University of Texas Southwestern Medical Center toassess how often the subject has taken, and whether he or she has madeany changes to his/her antidepressant treatment regimen in the last 2weeks. The total score was calculated by adding response choices forquestions 1c through 1f, with 0=adherent and 1 or more=nonadherent.

Sample Collection and Handling

The actual dates and times of sample collection were recorded in theeCRF or laboratory requisition form. If blood samples were collected viaan indwelling cannula, an appropriate amount (1 mL) of serosanguineousfluid slightly greater than the dead space volume of the lock wasremoved from the cannula and discarded before each blood sample istaken. After blood sample collection, the cannula was flushed with 0.9%sodium chloride, United States Pharmacopeia (USP) (or equivalent) andcharged with a volume equal to the dead space volume of the lock.

Subject Completion/Withdrawal Completion

A subject was considered to have completed the double-blind inductionphase of the study if he or she completed the MADRS assessment at theend of the 4-week double-blind induction phase (i.e., Day 28 MADRS).Subjects who prematurely discontinued study treatment for any reasonbefore completion of the double-blind induction phase were notconsidered to have completed the double-blind induction phase of thestudy. Subjects who entered the follow-up phase were considered to havecompleted this phase of the study if he or she had completed the MADRSassessment at Week 24 of the follow-up phase.

Withdrawal from the StudyA subject was withdrawn from the study for any of the following reasons:

-   -   1. Lost to follow-up    -   2. Withdrawal of consent    -   3. Violation of protocol procedures (determined on a        case-by-case basis)    -   4. Blind was broken (double-blind induction phase)    -   5. Lack of efficacy    -   6. The investigator or sponsor believed (e.g., that for safety        or tolerability reasons such as an adverse event) it was in the        best interest of the subject to discontinue the study.    -   7. Subject became pregnant    -   8. Study was terminated by sponsor for futility    -   9. Death

If a subject was lost to follow-up, every reasonable effort was made bythe study site personnel to contact the subject and determine the reasonfor discontinuation/withdrawal.

When a subject withdrew before completing the study, the reason forwithdrawal was documented. Study drug assigned to the withdrawn subjectwas not assigned to another subject. If a subject withdrew from thestudy before the end of the double-blind induction phase for reasonsother than withdrawal of consent, an early withdrawal visit wasconducted within 1 week of the date of discontinuation, followed by thefollow-up phase.

Safety Analyses

Safety data was analyzed for the double-blind induction phase using thesafety analysis set.

Adverse Events

The verbatim terms used in the eCRF by investigators to identify adverseevents were coded using the MedDRA. All reported adverse events withonset during the double-blind induction phase (i.e., TEAEs, and adverseevents that have worsened since baseline) were included in the analysis.For each adverse event, the percentage of subjects who experience atleast 1 occurrence of the given event was summarized by treatment group.Adverse events occurring during the follow-up phase were summarizedseparately.

TEAEs of special interest were examined separately. AEs of specialinterest were listed in the SAP. Subjects who died, who discontinuedtreatment due to an adverse event, or who experienced a severe or aserious adverse event were summarized separately.

Clinical Laboratory Tests

Laboratory data were summarized by type of laboratory test. Referenceranges and markedly abnormal results (specified in the StatisticalAnalysis Plan) were used in the summary of laboratory data. Descriptivestatistics were calculated for each laboratory analyte at baseline andat each scheduled time point in each phase of the study. Changes frombaseline results were presented. Frequency tabulations of theabnormalities were provided. Listings of subjects with laboratoryresults outside the reference ranges and markedly abnormal results wereprovided.

ECG

The effects on cardiovascular variables were evaluated by means ofdescriptive statistics and frequency tabulations. These tables includeobserved values and change from baseline values.

Electrocardiogram data was summarized by ECG parameter. Descriptivestatistics were calculated at baseline and for observed values andchanges from baseline at each scheduled time point. Frequencytabulations of the abnormalities were made.

The ECG variables that were analyzed were heart rate, PR interval, QRSinterval, QT interval, and QTc interval using the following correctionmethods: QT corrected according to Bazett's formula (QTcB) and QTcF.

Descriptive statistics of QTc intervals and changes from double-blindbaseline were summarized at each scheduled time point. The percentage ofsubjects with QTc interval >450 msec, >480 msec, or >500 msec weresummarized, as will the percentage of subjects with QTc intervalincreases from baseline <30 msec, 30-60 msec, or >60 msec.

All important abnormalities in ECG waveform that were changes from thebaseline readings were reported (e.g., changes in T-wave morphology orthe occurrence of U-waves).

Vital Signs

Descriptive statistics of temperature, pulse/heart rate, respiratoryrate, pulse oximetry, and blood pressure (systolic and diastolic)(supine) values and changes from baseline were summarized at eachscheduled time point. The percentage of subjects with values beyondclinically important limits were summarized.

Nasal Examination

Changes in findings from the baseline nasal examination (including theupper respiratory tract/throat) were listed by treatment group.Examinations provided ratings (absent, mild, moderate, or severe) thatwere based on a visual inspection of the nostrils, nasal mucosa, andthroat for nasal erythema, rhinorrhea, rhinitis, capillary/blood vesseldisruption and epistaxis. A shift table for changes from double-blindbaseline in ratings for each examination was presented by treatmentgroup.

Nasal Symptom Questionnaire

Scoring from the nasal symptom questionnaire was summarizeddescriptively for each scheduled time point by treatment group.

C-SSRS

Suicide-related thoughts and behaviors based on the C-SSRS weresummarized by treatment group in incidence and shift tables. Separateendpoints for suicidal ideation and suicidal behavior were defined andsummarized descriptively by treatment group. Missing scores were notimputed.

CADSS, BPRS+, and MOAA/S

Descriptive statistics of each score and changes from pre-dose weresummarized at each scheduled time point.

Clinical Global Assessment of Discharge Readiness, PWC-20, BPIC-SS,UPSIT, and Smell Threshold Test

Descriptive statistics of each score and changes and/or percent changesfrom baseline were summarized at each scheduled time point.

Cognition Testing

Descriptive statistics of the cognitive domain scores and changes frombaseline were summarized at each scheduled time point.

Adverse Event Definitions and Classifications

An adverse event is any untoward medical occurrence in a clinical studysubject administered a medicinal (investigational ornon-investigational) product. An adverse event does not necessarily havea causal relationship with the treatment. An adverse event can thereforebe any unfavorable and unintended sign (including an abnormal finding),symptom, or disease temporally associated with the use of a medicinal(investigational or non-investigational) product, whether or not relatedto that medicinal (investigational or non-investigational) product(definition per International Conference on Harmonisation [ICH]). Thisincludes any occurrence that is new in onset or aggravated in severityor frequency from the baseline condition, or abnormal results ofdiagnostic procedures, including laboratory test abnormalities.

A serious adverse event based on ICH and EU Guidelines onPharmacovigilance for Medicinal Products for Human Use is any untowardmedical occurrence that at any dose:

-   -   Results in death    -   Is life-threatening (for example, the subject was at risk of        death at the time of the event. “Life threatening” does not        refer to an event that hypothetically might have caused death if        it were more severe.)    -   Requires inpatient hospitalization or prolongation of existing        hospitalization    -   Results in persistent or significant disability/incapacity    -   Is a congenital anomaly/birth defect    -   Is a suspected transmission of any infectious agent via a        medicinal product    -   Is medically important*

*Medical and scientific judgment should be exercised in deciding whetherexpedited reporting is also appropriate in other situations, such asimportant medical events that may not be immediately life threatening orresult in death or hospitalization but may jeopardize the subject or mayrequire intervention to prevent one of the other outcomes listed in thedefinition above. These should usually be considered serious.

If a serious and unexpected adverse event occurred for which there isevidence suggesting a causal relationship between the study drug and theevent (e.g., death from anaphylaxis), the event was reported as aserious and unexpected suspected adverse reaction even if it was acomponent of the study endpoint (e.g., all-cause mortality).

An adverse event was considered unlisted if the nature or severity wasnot consistent with the applicable product reference safety information.For esketamine, the expectedness of an adverse event was determined bywhether or not it was listed in the Reference Safety Information Sectionof the Investigator's Brochure.

For duloxetine, escitalopram, sertraline, and venlafaxine XR, theexpectedness of an adverse event was determined by whether or not it islisted in the SmPC or US prescribing information.

An adverse event was considered associated with the use of the drug ifthe attribution was possible, probable, or very likely by theattribution definitions listed below.

Not Related: An adverse event that was not related to the use of thedrug.

Doubtful: An adverse event for which an alterative explanation was morelikely, e.g., concomitant drug(s), concomitant disease(s), or therelationship in time suggests that a causal relationship is unlikely.

Possible: An adverse event that might be due to the use of the drug. Analternative explanation, e.g., concomitant drug(s), concomitantdisease(s), was inconclusive. The relationship in time was reasonable;therefore, the causal relationship could not be excluded.

Probable: An adverse event that might be due to the use of the drug. Therelationship in time was suggestive (e.g., confirmed by dechallenge). Analternative explanation was less likely, e.g., concomitant drug(s),concomitant disease(s).

Very Likely: An adverse event that was listed as a possible adversereaction and could not be reasonably explained by an alternativeexplanation, e.g., concomitant drug(s), concomitant disease(s). Therelationship in time was very suggestive (e.g., it is confirmed bydechallenge and rechallenge).

An assessment of severity grade was made using the following generalcategorical descriptors:

Mild: Awareness of symptoms that were easily tolerated, causing minimaldiscomfort and not interfering with everyday activities.

Moderate: Sufficient discomfort was present to cause interference withnormal activity.

Severe: Extreme distress, causing significant impairment of functioningor incapacitation. Prevented normal everyday activities.

The investigator used clinical judgment in assessing the severity ofevents not directly experienced by the subject (e.g., laboratoryabnormalities).

Special Reporting Situations

Safety events of interest on a sponsor study drug that may requireexpedited reporting and/or safety evaluation included, but were notlimited to:

Overdose of a sponsor study drug

Suspected abuse/misuse of a sponsor study drug

Inadvertent or accidental exposure to a sponsor study drug

Medication error involving a sponsor product (with or withoutsubject/patient exposure to the sponsor study drug, e.g., nameconfusion)

Special reporting situations were recorded in the eCRF. Any specialreporting situation that met the criteria of a serious adverse event wasrecorded on the serious adverse event page of the eCRF.

Procedures: All Adverse Events

All adverse events and special reporting situations, whether serious ornon-serious, were reported from the time a signed and dated ICF wasobtained until completion of the subject's last study-related procedure(which may include contact for follow-up of safety). Serious adverseevents, including those spontaneously reported to the investigatorwithin 30 days after the last dose of study drug, were reported usingthe Serious Adverse Event Form. The sponsor evaluated any safetyinformation that was spontaneously reported by an investigator beyondthe time frame specified in the protocol.

All events that met the definition of a serious adverse event werereported as serious adverse events, regardless of whether they wereprotocol-specific assessments. Anticipated events were recorded andreported.

All adverse events, regardless of seriousness, severity, or presumedrelationship to study drug, were recorded using medical terminology inthe source document and the eCRF. Whenever possible, diagnoses weregiven when signs and symptoms were due to a common etiology (e.g.,cough, runny nose, sneezing, sore throat, and head congestion should bereported as “upper respiratory infection”). Investigators recorded inthe eCRF their opinion concerning the relationship of the adverse eventto study therapy. All measures required for adverse event managementwere recorded in the source document and reported.

The sponsor assumed responsibility for appropriate reporting of adverseevents to the regulatory authorities.

For all studies with an outpatient phase, including open-label studies,the subject was provided with a “Wallet (study) card” and instructed tocarry this card with them for the duration of the study indicating thefollowing:

-   -   Study number    -   Statement, in the local language(s), that the subject is        participating in a clinical study    -   Investigators name and 24-hour contact telephone number    -   Local sponsor's name and 24-hour contact telephone number (for        medical staff only)    -   Site number    -   Subject number    -   Any other information that is required to do an emergency        breaking of the blind

Serious Adverse Events

All serious adverse events occurring during the study were reported tothe appropriate sponsor contact person by study-site personnel within 24hours of their knowledge of the event.

All serious adverse events that were not resolved by the end of thestudy, or that were not resolved upon discontinuation of the subject'sparticipation in the study, were followed until any of the followingoccurs:

-   -   The event resolved    -   The event stabilized    -   The event returned to baseline, if a baseline value/status is        available    -   The event could be attributed to agents other than the study        drug or to factors unrelated to study conduct    -   It became unlikely that any additional information could be        obtained (subject or health care practitioner refusal to provide        additional information, lost to follow-up after demonstration of        due diligence with follow-up efforts)

Suspected transmission of an infectious agent by a medicinal product wasreported as a serious adverse event. Any event requiring hospitalization(or prolongation of hospitalization) that occurred during the course ofa subject's participation in a study was reported as a serious adverseevent, except hospitalizations for the following:

-   -   Hospitalizations not intended to treat an acute illness or        adverse event (e.g., social reasons such as pending placement in        long-term care facility)    -   Surgery or procedure planned before entry into the study (must        be documented in the eCRF). Hospitalizations that were planned        before the signing of the ICF, and where the underlying        condition for which the hospitalization was planned had not        worsened, were not considered serious adverse events. Any        adverse event that resulted in a prolongation of the originally        planned hospitalization was to be reported as a new serious        adverse event.

For convenience the investigator was able to choose to hospitalize thesubject for the duration of the treatment period.

The cause of death of a subject in a study, whether or not the event wasexpected or associated with the study drug, was considered a seriousadverse event.

Pregnancy

All initial reports of pregnancy were to be reported to the sponsor bythe study-site personnel within 24 hours of their knowledge of the eventusing the appropriate pregnancy notification form. Abnormal pregnancyoutcomes (e.g., spontaneous abortion, stillbirth, and congenitalanomaly) were considered serious adverse events and were to be reportedusing the Serious Adverse Event Form. Any subject who became pregnantduring the study was to promptly withdraw from the study and discontinuefurther study treatment.

Because the effect of the study drug on sperm is unknown, pregnancies inpartners of male subjects included in the study was to be reported bythe study-site personnel within 24 hours of their knowledge of the eventusing the appropriate pregnancy notification form.

Follow-up information regarding the outcome of the pregnancy and anypostnatal sequelae in the infant was required.

Summary of all Adverse Events

An overall summary of all treatment-emergent adverse events (TEAEs)during the double-blind phase is presented in Table 18. Overall, 84.3%of subjects in the esketamine+oral AD group and 60.6% of subjects in theactive comparator group experienced at least one TEAE during thedouble-blind phase.

TABLE 18 Overall Summary of Treatment-emergent Adverse Events;Double-blind Induction Phase (Study ESKETINTRD3002: Safety Analysis Set)Oral AD + Intranasal Esk + Intranasal Placebo Oral AD (N = 115) (N =109) TEAE 97 (84.3%) 66 (60.6%) TEAE possibly related to 90 (78.3%) 39(35.8%) intranasal drug ^(a) TEAE possibly related to oral 37 (32.2%) 26(23.9%) antidepressant ^(a) TEAE leading to death 0 0 1 or more seriousTEAE 1 (0.9%) 1 (0.9%) TEAE leading to intranasal 8 (7.0%) 1 (0.9%) drugwithdrawn ^(b) TEAE leading to oral 4 (3.5%) 0 antidepressant withdrawn^(b) ^(a) Study drug relationships of possible, probable, and verylikely are included in this category. ^(b) An adverse event that startedin the double-blind induction phase and resulted in discontinuation inthe follow-up phase was counted as treatment-emergent in thedouble-blind induction phase. Incidence was based on the number ofsubjects experiencing at least one adverse event, not the number ofevents.

FIG. 6 shows the percentage of subjects reporting problems at baselineand endpoint as determined by EQ-5D-% L individual dimensions.

Treatment-emergent adverse events occurring during the double-blindphase (≥5% of subjects in either treatment group) are summarized bytreatment group for the safety analysis set in Table 19, below. The mostcommon (≥20%) TEAEs in the esketamine+oral AD group during thedouble-blind phase were nausea (26.1%), vertigo (26.1%), dysgeusia(24.3%), and dizziness (20.9%). The most common TEAE in the activecomparator group was headache (17.4%).

TABLE 19 Treatment-emergent Adverse Events in at Least 5% of Subjects inEither Treatment Group; Double-blind Induction Phase (StudyESKETINTRD3002: Safety Analysis Set) Oral AD + Intranasal Esk +Intranasal Placebo Oral AD (N = 115) (N = 109) Total no. subjects withTEAE 97 (84.3%) 66 (60.6%) Nervous system disorders 72 (62.6%) 38(34.9%) Dysgeusia 28 (24.3%) 13 (11.9%) Dizziness 24 (20.9%) 5 (4.6%)Headache 21 (18.3%) 19 (17.4%) Somnolence 15 (13.0%) 7 (6.4%)Paresthesia 13 (11.3%) 1 (0.9%) Dizziness postural 8 (7.0%) 1 (0.9%)Hypoesthesia 8 (7.0%) 1 (0.9%) Gastrointestinal disorders 52 (45.2%) 26(23.9%) Nausea 30 (26.1%) 7 (6.4%) Vomiting 11 (9.6%)  2 (1.8%) Diarrhea10 (8.7%)  10 (9.2%)  Dry mouth 9 (7.8%) 3 (2.8%) Hypoesthesia oral 9(7.8%) 1 (0.9%) Paresthesia oral 9 (7.8%) 1 (0.9%) Psychiatric disorders52 (45.2%) 20 (18.3%) Dissociation 14 (12.2%) 2 (1.8%) Anxiety 12(10.4%) 5 (4.6%) Insomnia 11 (9.6%)  6 (5.5%) Derealisation 9 (7.8%) 2(1.8%) Delusional perception 6 (5.2%) 0 Illusion 6 (5.2%) 1 (0.9%) Earand labyrinth disorders 34 (29.6%) 6 (5.5%) Vertigo 30 (26.1%) 3 (2.8%)General disorders and 34 (29.6%) 14 (12.8%) administration siteconditions Feeling abnormal 10 (8.7%)  1 (0.9%) Feeling drunk 8 (7.0%) 1(0.9%) Fatigue 5 (4.3%) 6 (5.5%) Respiratory, thoracic and 25 (21.7%) 15(13.8%) mediastinal disorders Throat irritation 9 (7.8%) 5 (4.6%) Nasaldiscomfort 8 (7.0%) 2 (1.8%) Eye disorders 18 (15.7%) 3 (2.8%) Visionblurred 14 (12.2%) 3 (2.8%) Investigations 14 (12.2%) 4 (3.7%) Bloodpressure increased 11 (9.6%)  0 Incidence was based on the number ofsubjects experiencing at least one adverse event, not the number ofevents.

Adverse Events Leading to Study Drug Withdrawal

There were 9 subjects (8 subjects in the esketamine+oral AD group and 1subject in the active comparator group) who discontinued thedouble-blind induction phase intranasal study medication due totreatment-emergent adverse events (Table 20). There were 4 subjects inthe esketamine+oral AD group who discontinued the double-blind inductionphase oral antidepressant study medication due to treatment-emergentadverse events (Table 21). Three subjects in the esketamine+oral ADgroup discontinued the double-blind phase due to both intranasal andoral AD medications. (Summarized in both Table 20 and 21).

TABLE 20 Treatment-emergent Adverse Events Leading to Discontinuation ofIntranasal Study Medication; Double-blind Induction Phase (StudyESKETINTRD3002: Safety Analysis Set) Oral AD + Intranasal Esk +Intranasal Placebo Oral AD (N = 115) (N = 109) Total no. subjects withTEAE 8 (7.0%) 1 (0.9%) leading to discontinuation ^(a) Psychiatricdisorders 4 (3.5%) 0 Anxiety 1 (0.9%) 0 Depression 1 (0.9%) 0 Depressivesymptom 1 (0.9%) 0 Panic attack 1 (0.9%) 0 General disorders and 2(1.7%) 0 administration site conditions Drug intolerance 1 (0.9%) 0Feeling drunk 1 (0.9%) 0 Nervous system disorders 2 (1.7%) 0 Dizziness 1(0.9%) 0 Headache 1 (0.9%) 0 Ear and labyrinth disorders 1 (0.9%) 0Vertigo 1 (0.9%) 0 Gastrointestinal disorders 1 (0.9%) 0 Nausea 1 (0.9%)0 Injury, poisoning and procedural 1 (0.9%) 0 complications Multipleinjuries 1 (0.9%) 0 Skin and subcutaneous tissue 0 1 (0.9%) disordersRash generalized 0 1 (0.9%) ^(a) An adverse event that started in thedouble-blind induction phase and resulted in discontinuation in thefollow-up phase was counted as treatment-emergent in the double-blindinduction phase. Incidence was based on the number of subjectsexperiencing at least one adverse event, not the number of events.

TABLE 21 Treatment-emergent Adverse Events Leading to Discontinuation ofOral Antidepressant; Double-blind Induction Phase (Study ESKETINTRD3002:Safety Analysis Set) Oral AD + Intranasal Esk + Intranasal Placebo OralAD (N = 115) (N = 109) Total no. subjects with TEAE 4 (3.5%) 0 leadingto discontinuation ^(a) Psychiatric disorders 2 (1.7%) 0 Depressivesymptom 2 (1.7%) 0 General disorders and 1 (0.9%) 0 administration siteconditions Drug intolerance 1 (0.9%) 0 Injury, poisoning and procedural1 (0.9%) 0 complications Multiple injuries 1 (0.9%) 0 ^(a) An adverseevent that started in the double-blind induction phase and resulted indiscontinuation in the follow-up phase was counted as treatment-emergentin the double-blind induction phase. Incidence was based on the numberof subjects experiencing at least one adverse event, not the number ofevents.

Two subjects experienced a serious treatment-emergent adverse eventduring the double-blind phase. One subject in the active comparatorgroup experienced positional vertigo which was consider of doubtfulrelationship to both intranasal placebo and oral AD. One subject in theesketamine+oral AD group experienced multiple injuries due to amotorbike accident (and subsequently died after formal database lock).This event was considered not related to esketamine and of doubtfulrelationship to the oral AD.

One subject in the esketamine+oral AD group experienced a cerebralhemorrhage during the follow up phase 83 days after the last intranasaladministration of esketamine. This was considered of doubtfulrelationship to esketamine and not related to the oral AD.

Blood Pressure

Transient blood pressure increases peaked for the esketamine group atapproximately 40 minutes post dose and returned to normal range at 90minutes. The maximum mean increases (across all dosing days) in systolicBP was 11.6 in the esketamine+oral AD group and 5.0 in the activecomparator group. The maximum mean increase (across all dosing days) indiastolic BP were 8.1 in the esketamine group and 4.5 in the activecomparator group. FIGS. 7 and 8 present the means for measured bloodpressure over time by treatment group in the double-blind phase.

Clinician-Assessed Dissociative Symptom Scale (CADSS)

The Clinician Administered Dissociative States Scale (CADSS) wasmeasured prior to the start of each dose, at 40 minutes, and 1.5 hourspostdose. The CADSS was used to assess treatment emergent dissociativesymptoms and perceptual changes and the total score ranged from 0 to 92with a higher score representing a more severe condition. Thedissociative and perceptual change symptoms measured by the CADSS,suggest these symptoms had an onset shortly after the start of the doseand resolved by 1.5 hours postdose (as shown in FIG. 9).

Modified Observer's Assessment of Alertness/Sedation (MOAA/S)

The Modified Observer's Assessment of Alertness/Sedation (MOAA/S) wasused to measure treatment-emergent sedation with correlation to levelsof sedation defined by the American Society of Anesthesiologists (ASA)continuum. The MOAA/S scores ranged from 0 (No response to painfulstimulus; corresponds to ASA continuum for general anesthesia) to 5(Readily responds to name spoken in normal tone [awake]; correspondingto ASA continuum for minimal sedation). Sedation as measured by theMOAA/S, suggests that sedation resolved by 1.5 hours postdose (as shownin FIG. 10).

Pharmacokinetics

Venous blood samples of approximately 2 mL were collected formeasurement of plasma concentrations of esketamine, noresketamine, andother metabolites (if warranted) at the time points specified in theTime and Events Schedule. The exact dates and times of PK blood samplingwere recorded.

Plasma samples were analyzed to determine concentrations of esketamine(and noresketamine, if warranted) using a validated, specific, achiral,and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS)method by or under the supervision of the sponsor. If required, someplasma samples were analyzed to document the presence of other analytes(e.g., circulating metabolites or denatonium) using a qualified researchmethod. In addition, plasma PK samples could be stored for futureanalysis of the metabolite profile.

Pharmacokinetic Parameters

The plasma concentration-time data of esketamine (and noresketamine, ifwarranted) was analyzed using population PK modeling. Typical populationvalues of basic PK parameters (e.g., esketamine clearance distributionvolume) were estimated together with the inter-individual variability.Effects of subject demographics, laboratory parameter values, and othercovariates on the PK of esketamine were explored.

Pharmacokinetic/Pharmacodynamic Evaluations

The relationship between MADRS total score (and possibly selectedadverse events as additional PD parameters) and PK metrics of esketaminewere evaluated. If there was any visual trend in graphical analysis,suitable models were applied to describe the exposure-effectrelationships.

Biomarker, Pharmacogenomic (DNA), and Expression (RNA) Evaluations

During the study, blood was collected for the assessment of biomarkersat the time points indicated in the Time and Events schedule. Thebiomarker blood samples were collected prior to dosing. It was preferredthat subjects adhere to a low fat diet on the day of sample collection.

In blood, biomarkers (protein, metabolite, and ribonucleic acid [RNA])related to (but not limited to) the immune system activity, hypothalamuspituitary adrenal (HPA) axis activation, neurotrophic factors, andmetabolic factors were investigated. Biomarkers were added or deletedbased on scientific information or technical innovations under thecondition that the total volume of blood collected was not increased.

Blood samples for DNA analyses were collected at the time pointsindicated in the Time and Events Schedule for the assessment of geneticand epigenetic variation in genes in pathways relevant to depression(e.g., HPA axis, inflammation, growth factors, monoamine transporters,ion channels, and circadian rhythm). Genotyping was conducted only onthe screening sample; pharmacogenomic and epigenetic evaluations couldbe performed on any/all collected samples.

DNA samples were used for research related to esketamine, oralantidepressants, TRD, or MDD. They could also be used to developtests/assays related to esketamine, oral antidepressants, TRD, or MDD.Pharmacogenomic research consisted of the analysis of 1 or morecandidate genes or of the analysis of genetic markers throughout thegenome (as appropriate) in relation to esketamine, oral antidepressants,TRD, or MDD clinical endpoints.

Medical Resource Utilization

Medical resource utilization data, associated with medical encounters,were collected during the follow-up phase of the study.Protocol-mandated procedures, tests, and encounters were excluded. Thedata collected could be used to conduct exploratory economic analysesand include: (a) Number and duration of medical care encounters,including surgeries, and other selected procedures (inpatient andoutpatient), (b) Duration of hospitalization (total days length of stay,including duration by wards; e.g., intensive care unit), (c) Number andcharacter of diagnostic and therapeutic tests and procedures, and/or (d)Outpatient medical encounters and treatments (including physician oremergency room visits, tests and procedures, and medications).

Pharmacokinetic Analyses

Plasma esketamine (and noresketamine, if warranted) concentrations werelisted for all subjects. The plasma concentration-time data ofesketamine (and noresketamine, if warranted) was analyzed usingpopulation PK modeling. Data may have been combined with those of otherselected studies to support a relevant structural model. Typicalpopulation values of basic PK parameters were estimated together withthe inter-individual variability. Effects of subject demographics,laboratory parameter values, and other covariates on the PK ofesketamine were explored.

Pharmacokinetic/Pharmacodynamic Analyses

The relationship between MADRS total score (and possibly selectedadverse events as additional PD parameters) and PK metrics of esketaminewere evaluated. If there was any visual trend in graphical analysis,suitable models were applied to describe the exposure-effectrelationships.

Biomarker and Pharmacogenomic Analyses

Baseline biomarker values and changes from baseline biomarker values tothe time points specified in the Time and Events Schedule weresummarized. Exploratory analyses may have included comparison ofbiomarker measures between the treatment groups and correlation withbaseline and change from baseline biomarker values in the efficacy andother measures. Additional exploratory analyses may have also includedrelationship of baseline and change from baseline in biomarker measuresto clinical response, maintenance/stabilization of response, relapse,and non-response.

Pharmacogenomic analyses may also have included candidate gene analysesor genome-wide association analyses in relation to treatment response,maintenance/stabilization of response, relapse, non-response, andMDD/TRD. Expression analyses may include testing of known messengerRNA/microRNA (mRNA/miRNA) transcripts or transcriptome-wide analysis inrelationship to antidepressant treatment response and MDD/TRD.

Statistical Methods Used in Analysis

A general description of the statistical methods used to analyze theefficacy and safety data is outlined below. At the end of thedouble-blind induction phase the database was locked for the analysisand reporting of this phase. The subject treatment assignment wasrevealed only to sponsor's study staff. The investigators and the sitepersonnel were blinded to the treatment assignment until all subjectshad completed study participation through the follow-up phase.

The primary efficacy and safety analysis sets were as follows:

Full Analysis Set: All randomized subjects who received at least 1 doseof intranasal study medication and 1 dose of oral antidepressant in thedouble-blind induction phase.

Safety Analysis Set: All randomized subjects who received at least 1dose of intranasal study medication or 1 dose of oral antidepressant inthe double-blind induction phase.

The maximum sample size planned for this study was calculated assuming atreatment difference for the double-blind induction phase of 6.5 pointsin MADRS total score between esketamine and the active comparator, astandard deviation of 12, a 1-sided significance level of 0.0125, and adrop-out rate of 25%. A maximum of about 98 subjects would need to berandomized to each treatment group to achieve 90% power using a fixeddesign with no interim analysis. The treatment difference and standarddeviation used in this calculation were based on results of Panel A ofthe ESKETINTRD2003 study and on clinical judgment.

Interim Analysis for Sample Size Re-Estimation or Stopping for Futility

One unblinded interim analysis was performed 4 weeks after randomizing66 subjects in the study (approximately 33 subjects per treatment arm).It was projected that at that time approximately 50 subjects in the fullanalysis set would have completed the double-blind induction phase ofthe study (approximately 25 subjects per treatment group). The dropoutrate was monitored to ensure a sufficient number of subjects wereincluded in the interim analysis. The purpose of the interim analysiswas to either re-estimate sample size or to stop the study due tofutility. The sample size could be adjusted to achieve the desired powerwhile maintaining control of the overall Type I error. The maximumsample size planned for this study was 98 per treatment group.

A rigorous interim statistical analysis plan (SAP) and charter wasdeveloped detailing the algorithm for a sample size re-estimation basedon the interim data and how the analysis was executed. An IDMC performedthe interim analysis and made recommendations for any sample sizeadjustment based on the rules defined in the interim SAP. Any changes tosample size were communicated IDMC (or the statistician from theStatistical Support Group) to the IWRS vendor to ensure that theappropriate number of subjects were enrolled in the study. None of theesketamine team members or staff members at the investigational sitesconducting the clinical study were informed of the results of theinterim analysis and any adjustments that were made to the sample size.

Procedures were in place to ensure that the results of the interimanalysis did not influence the conduct of the study, investigators, orsubjects.

Efficacy Analyses

Efficacy analyses were performed on the full analysis set, whichincluded all randomized subjects who received at least 1 dose ofintranasal study drug and 1 dose of oral antidepressant medication inthe double-blind induction phase.

The primary efficacy variable, change from baseline in MADRS total scoreat Week 4 in the double-blind induction phase, was analyzed using MMRM.The model included baseline MADRS total score as a covariate, andtreatment, country, class of antidepressant (SNRI or SSRI), day, andday-by-treatment interaction as fixed effects, and a random subjecteffect. Comparison of the esketamine plus oral antidepressant arm versusoral antidepressant plus intranasal placebo was performed using theappropriate contrast.

For the EU dossier, the primary efficacy analysis was based on ananalysis of covariance (ANCOVA) model using last observation carriedforward (LOCF) data. The model included factors for treatment, country,and class of oral antidepressant (SNRI or SSRI) and baseline MADRS totalscore as a covariate. Comparison of the esketamine plus oralantidepressant arm versus intranasal placebo plus oral antidepressantwas performed using the appropriate contrast.

Subject to regulatory acceptance of PHQ-9 as a key secondary endpoint,the first of 3 key secondary efficacy endpoints, change from baseline inPHQ-9 total score at Week 4 in the double-blind induction phase, wereanalyzed using the same models described above for the MADRS totalscore.

For the analysis of the second key secondary efficacy endpoints, theproportion of subjects showing onset of clinical response by Day 2 thatis maintained for the duration of the double-blind induction phase inthe esketamine plus oral antidepressant arm was compared with the oralantidepressant plus intranasal placebo arm using aCochran-Mantel-Haenszel chi-square test adjusting for country and classof antidepressant (SNRI or SSRI). Clinical response was defined as ≥50%improvement in MADRS total score by Day 2 (i.e., the day after takingthe first dose of double-blind intranasal medication) that continuesthrough the end of the double-blind phase. Subjects who discontinued thestudy prior to end of the double-blind induction phase were notconsidered to have maintained clinical response.

The third key secondary efficacy endpoint, change from baseline in SDStotal score at Week 4 in the double-blind induction phase, was analyzedusing ANCOVA. The model included factors for treatment, country, andclass of oral antidepressant (SNRI or SSRI) and baseline SDS total scoreas a covariate. Comparison of each intranasal esketamine plus oralantidepressant arm versus oral antidepressant plus intranasal placebowas performed using the appropriate contrast. Responses to questions H1to H3 was summarized separately.

A serial gatekeeping (fixed sequence) approach was applied to adjust formultiplicity and to strongly control type I error across the primary andthe 3 key secondary efficacy endpoints (change in PHQ-9 total score,onset of clinical response, and change in SDS total score).

Response and remission rates were summarized at each visit.

Change from baseline in GAD-7 total scores and ranks of change frombaseline in CGI-S scores at the end of the double-blind induction phasewere analyzed based on LOCF data using an ANCOVA model, with country andclass of antidepressant (SNRI or SSRI) as factors, and the respectivebaseline score (unranked score in the case of CGI-S) as the covariate.

Dimension scores of EQ-5D-5L data, health status index, and the overallhealth status score were summarized over time.

Additionally, scores of all efficacy endpoints were summarized for allvisits in the double-blind induction phase. Summaries were provided toshow consistency of effect among relevant subgroups (e.g.,antidepressant class SNRI and SSRI).

Analysis of the US Subpopulation—Clinical Efficacy and Safety

In the overall analysis, ESK+AD demonstrated statistically significantand clinically meaningful superiority compared with AD+PBO in primaryefficacy endpoint (i.e., change from baseline in the MADRS total score(Montgomery, British Journal of Psychiatry. 1979; 134:382-389)). In thisanalysis, the efficacy and safety of these treatment groups wereanalyzed in only US patients and to assess for differences in efficacyand safety between the US population and the overall study population.

A. Outcomes

For the clinician-rated assessments, MADRS was administered at baseline;and days 2 (˜24 hours post dose), 8, 15, 22, and 28. Similarly, theClinical Global Impressions-Severity (CGI-S) scale (Guy W. ECDEUAssessment Manual for Psychopharmacology (028 Clinical GlobalImpressions [CGI]). 1976:218-222) administered at baseline; days 4, 8,11, 15, 22; and at the 4-week double blind end point.

For the patient-rated assessments, a 9-item Patient HealthQuestionnaire-9 (PHQ-9) (Spitzer, JAMA. 1999; 282(18):1737-1744) andSheehan Disability Scale (SDS) (Sheehan DV. The Anxiety Disease. ALeading Psychiatrist Offers New Hope for Victims of Severe Anxiety. NewYork, N.Y.: Charles Scribner & Sons; 1983) were administered atbaseline, day 15 and day 28.

B. Patient Demographics/Disease Characteristics

Inclusion criteria included adults, aged 18 to 64 years (inclusive), whomet DSM-diagnostic criteria for MDD confirmed by Mini-InternationalNeuropsychiatric Interview, and Inventory of DepressiveSymptomatology-Clinician rated, 30-item total score of 234 (moderate tosevere depression)

Patients must have had TRD and non-response at the end of the screeningphase, defined as ≤25% improvement in MADRS total score from Week 1 toWeek 4 and a MADRS total score of ≥28 on Week 2 and Week 4.

Of the 91 US patients, 46 received ESK+AD, 44 received AD+PBO, and onedid not dose. The baseline patient demographics and diseasecharacteristics were generally similar between the 2 treatment groups.See, Table 22. The overall mean age was 44.1 year, and approximatelytwo-thirds (61.1%) of patients were women and most (83.3%) patients wereCaucasian. The mean age of MDD diagnosis was 27.5 years, indicating onaverage, a >15-year history of depression. The baseline MADRS, CGI-S andPHQ-9 scores were consistent with a population with TRD.

TABLE 22 Baseline patient demographics and disease characteristics ESK +AD AD + PBO Parameter (n = 46) (n = 44) Age, y, mean (SD) 43.4 (13.5)44.7 (12.4) Sex, n (%) Male 17 (37.0) 18 (40.9) Female 29 (63.0) 26(59.1) Race, n (%) Caucasian 38 (82.6) 37 (84.1) Black or AfricanAmerican 6 (13.0) 5 (11.4) Asian 1 (2.2) 1 (2.3) Multiple 1 (2.2) 1(2.3) Class of oral antidepressants, n (%)† SNRI 27 (58.7) 26 (59.1)SSRI 19 (41.3) 18 (40.9) Duration of current episode, 132.2 (109.8)177.6 (252.4) weeks, mean (SD) Age at MDD diagnosis, y, mean (SD) 25.5(11.8) 29.5 (14.0) MADRS total score,^(a) mean (SD) 36.6 (5.9) 36.0(6.0) CGI-S,^(b) mean (SD) 4.8 (0.6) 4.8 (0.7) SDS derived totalscore,^(c) mean (SD) 23.4 (4.5) 24.1 (4.9) PHQ-9 total score,^(d) mean(SD) 20.2 (3.3) 20.9 (3.8) ^(a)MADRS total score ranges from 0 to 60; ahigher score indicates a more severe condition. ^(b)CGI-S score rangesfrom 1 (normal, not at all ill) to 7 (among the most extremely illpatients). ^(c)SDS total scores range from 0 to 30, where 0 = unimpairedand 30 = highly impaired. ^(d)PHQ-9 total score ranges from 0 to 27; ahigher score indicates greater depression.

C. Efficacy

Efficacy was determined by measuring MADRS total scores, SDS scores,PHQ-9 scores and CGI-S scores. For the MADRS total scores, SDS scores,and PHQ-9 scores, the test for treatment effect was based on mixed modelfor repeated measures (MMRM) with change from baseline as the responsevariable and the fixed effect model terms for treatment (ESK+AD,AD+PBO), day, class of oral antidepressant (serotonin and norepinephrinereuptake inhibitor [SNRI] or selective serotonin reuptake inhibitor[SSRI]), treatment-by-day, and baseline value as a covariate. For theCGI-S scores, the test for treatment effect was based on analysis ofcovariance (ANCOVA) model last observation carried forward (LOCF) onranks of change from baseline as the response variable and factors fortreatment (ESK+AD, AD+PBO) and class of oral antidepressant (SNRI orSSRI), and baseline value (unranked) as a covariate. For each analysis,a negative difference favors esketamine nasal spray plus new oral AD.

The results illustrate that the least square (LS) mean changes in MADStotal score decreased in both treatment groups during the 4-weekdouble-blind induction phase. See, FIG. 11.

The treatment effect favored the ESK+AD group at about 24-hours postdose (day 2) and on day 28, with the difference reaching statisticalsignificance at day 28. See, Table 23. The LS mean difference (SE) was−1.6 (2.15; P=0.225) at about 24-hours post dose (day 2) and −5.5 (2.58;P=0.017) at day 28.

TABLE 23 Change from Baseline in MADRS total score (observed cases) inUS patients with TRD ESK + AD AD + PBO MADRS parameter (n = 46) (n = 44)Total score at baseline 36.6 (5.9) 36.0 (6.0) Change at day 2 (~24 hourspost-initial dose) LS mean change −10.4 −8.8 LS mean difference fromplacebo nasal spray −1.6 (2.15) plus new oral AD (SE) P value .225Change at day 28 LS mean change −19.2 −13.7 LS mean difference fromplacebo nasal spray −5.5 (2.58) plus new oral AD (SE) P value 017 MADRStotal score ranges from 0 to 60; a higher score indicates a more severecondition. AD, antidepressant; ESK, esketamine nasal spray; LS, leastsquare; MADRS, Montgomery-Åsberg Depression Rating Scale; PBO, placebonasal spray; SE, standard error.

A statistically significant difference in improvement of severity ofdepressive illness, as measured by the CGI-S, was observed between the 2treatment groups at day 4 (P=0.015). The difference approachedsignificance at 4-weeks post-initial dose (P=0.070). See, Table 24.

TABLE 24 Change in clinician-rated severity of depressive illness (LOCF)in US patients with TRD, as assessed with CGI-S. ESK + AD AD + PBO CGI-SParameter (n = 46) (n = 44) Baseline N 45 44 Median (range) 5.0 (4, 6)5.0 (4, 6) Day 4 post-initial dose N 42 38 Median (range) 4.0 (2, 6) 4.0(3, 6) Change from baseline at day 4 post-initial dose N 42 38 Median(range)  0.0 (−3, 0)  0.0 (−2, 1) 1-sided P value    0.015 4-week doubleblind end point N 44 44 Median (range) 3.0 (1, 6) 4.0 (1, 6) Change frombaseline to 4-week double blind end point N 44 44 Median (range) −1.5(−5, 1) −1.0 (−4, 1) 1-sided P value    0.070 CGI-S score ranges from 1(normal, not at all ill) to 7 (among the most extremely ill patients).AD, antidepressant; Clinical Global Impression - Severity; ESK,esketamine nasal spray; LOCF, last observation carried forward; Max,maximum; Min, minimum; PBO, placebo nasal spray.

The Patient-rated severity of depressive illness decreased in bothtreatment groups, but the magnitude of decrease was greater in theESK+AD group at day 28. See, FIG. 12. The mean PHQ-9 scores at baselinewere 20.2 in the ESK+AD group and 20.9 in the AD+PBO group. On day 28,mean PHQ-9 total scores were 8.0 and 11.7, respectively. LS meandifference (SE) in PHQ-9 was −3.1 (1.52; P=0.024).

Functional impairment decreased in both treatment groups, but themagnitude of improvement was greater in the ESK+AD group at day 28. See,FIG. 13. The mean SDS scores at baseline were 23.4 in the ESK+AD groupand 24.1 in the AD+PBO group. n day 28, mean derived SDS total scoreswere 9.7 and 16.7, respectively. LS mean difference (SE) in SDS totalscore was −5.2 (2.13; P=0.009).

D. Safety

Safety was assessed via treatment emergent adverse events (TEAEs),serious AEs, vital signs, psychiatric symptoms as assessed by BriefPsychiatric Rating Scale (BPRS), dissociation as measured by ClinicianAdministered Dissociative States Scale (CADSS), and discharge readiness.

Overall, TEAEs were observed in 91.3% of patients in the ESK+AD groupand 77.3% of patients in the AD+PBO group. See, Table 25A. There were nodeaths. One patient in the ESK+AD group experienced a SAE during thefollow-up phase (cerebral hemorrhage on day 98). Four patients withdrewfrom nasal spray drug (n=3 ESK; n=1 PBO); no patient withdrew new oralAD.

The most common TEAEs (≥5% in either treatment group) are shown in Table4. The incidence of TEAEs was similar between the US patients and theoverall study population. AEs observed during the study were mostly mildto moderate in severity and transient in nature.

As observed in the overall population, present-state dissociativesymptoms and transient perceptual effects as measured by the CADSS totalscore resolved spontaneously during the post dose observation periodprior to discharge (within 60-90 minutes post dose). Most (>90%)patients in each treatment group were ready for discharge by 1.5 hourspost dose. Vital sign and BPRS findings were consistent with the overallpopulation.

TABLE 25A Overview of treatment-emergent adverse events ESK + AD AD +PBO Parameter (n = 46) (n = 44) Overall TEAE, n (%) 42 (91.3) 34 (77.3)Possibly related to nasal spray drug 38 (82.6) 22 (50.0) Possiblyrelated to oral AD 23 (50.0) 15 (34.1) Leading to death 0 0 1 or moreserious TEAE 0 0 Leading to nasal spray drug withdrawal 3 (6.5) 1 (2.3)Leading to oral AD withdrawal 0 0 Most common (≥5%) TEAEs in eithertreatment group Dizziness 15 (32.6) 4 (9.1) Nausea 14 (30.4) 2 (4.5)Headache 13 (28.3)  8 (18.2) Dysgeusia 11 (23.9) 3 (6.8) Throatirritation 9 (19.6)  5 (11.4) Vertigo 9 (19.6) 1 (2.3) Nasal discomfort8 (17.4) 2 (4.5) Feeling abnormal 7 (15.2) 1 (2.3) Dissociation 6 (13.0)1 (2.3) Hypoesthesia 6 (13.0) 0 Insomnia 6 (13.0) 4 (9.1) Paresthesia 6(13.0) 1 (2.3) Anxiety 5 (10.9) 4 (9.1) Delusional perception 5 (10.9) 0Illusion 5 (10.9) 0 Hypoesthesia oral 5 (10.9) 1 (2.3) Vomiting 5 (10.9)1 (2.3) Dizziness postural 4 (8.7) 0 Diarrhea 4 (8.7) 4 (9.1) Feelingdrunk 4 (8.7) 1 (2.3) Rhinorrhea 4 (8.7) 0 Dysarthria 3 (6.5) 1 (2.3)Tunnel vision 3 (6.5) 1 (2.3) Derealization 3 (6.5) 0 Euphoric mood 3(6.5) 0 Dry mouth 3 (6.5) 2 (4.5) Blood pressure increased 3 (6.5) 0Somnolence 2 (4.3) 3 (6.8) Fatigue 2 (4.3)  5 (11.4)

E. Summary

These results demonstrated that ESK+AD provided a rapid onset of effectthat continued for 4 weeks and was generally well tolerated in USpatients with TRD. These observations agree with those from the overallstudy population, indicating that the US population had no significantdifferences in efficacy. In STAR-D level 3 (i.e., patients with MDD whodid not remit with level 1 or level 2 treatment) attainment of theprimary outcome (17-item Hamilton Rating Scale of Depression score ≤7)occurred in 8-12% of patients in ˜6 weeks' time. See, Rush, CNS Drugs.2009; 23(8):627-647. By comparison, at 4 weeks past-initial dose, ESK+ADresulted in improvements in LS mean change in MADRS total score,patient-rated severity of depressive illness, and functional impairment.

Moreover, a statistically significant improvement in clinician-ratedseverity of depressive illness was observed 24 hours after ESK+ADdosing. Improvements in clinician- and patient-rated efficacy measureswere noted in ESK+AD and AD+PBO treatment groups.

ESK+AD compared with AD+PBO (active comparator) in US patients with TRDprovided evidence for clinically meaningful, statistically significant,and rapid reduction of depressive symptoms. Significant improvements inclinician-rated severity of depressive illness were observed as early as24 hours after dosing in some patients.

Improvements in LS mean change in MADRS total score, patient-ratedseverity of depressive illness, and functional impairment were observedat 4 weeks post-initial dose.

Overall, safety and response/remission results of US patients weresimilar to those found for the overall population.

Final Analysis of the US Subpopulation—Response, Remission, and Safety

As discussed above for the overall analysis, ESK+AD demonstratedstatistically significant and clinically meaningful superiority comparedwith AD+PBO in primary efficacy endpoint (i.e., change from baseline inthe MADRS total score. See, Montgomery cited above. In this analysis,the response, remission, and safety of these treatment groups wereanalyzed in only US patients and to assess for differences in efficacyand safety between the US population and the overall study population.

A. Outcomes

For the clinician-rated assessments, MADRS was administered at baseline;and days 2 (˜24 hours post dose), 8, 15, 22, and 28. Similarly, theClinical Global Impressions-Severity (CGI-S) scale (Guy W. ECDEUAssessment Manual for Psychopharmacology (028 Clinical GlobalImpressions [CGI]). 1976:218-222) administered at baseline; days 4, 8,11, 15, 22; and at the 4-week double blind end point.

For the patient-rated assessments, a 9-item Patient HealthQuestionnaire-9 (PHQ-9) (Spitzer, JAMA. 1999; 282(18):1737-1744) andSheehan Disability Scale (SDS) (Sheehan DV. The Anxiety Disease. ALeading Psychiatrist Offers New Hope for Victims of Severe Anxiety. NewYork, N.Y.: Charles Scribner & Sons; 1983) were administered atbaseline, day 15 and day 28.

B. Patient Demographics/Disease Characteristics

Inclusion criteria included adults, aged 18 to 64 years (inclusive), whomet DSM-diagnostic criteria for MDD confirmed by Mini-InternationalNeuropsychiatric Interview, and Inventory of DepressiveSymptomatology-Clinician rated, 30-item total score of 234 (moderate tosevere depression).

Patients must have had TRD and non-response at the end of the screeningphase, defined as ≤25% improvement in MADRS total score from Week 1 toWeek 4 and a MADRS total score of ≥28 on Week 2 and Week 4.

Of the 91 US patients, 46 received ESK+AD, 44 received AD+PBO, and onedid not dose. The baseline patient demographics and diseasecharacteristics were generally similar between the 2 treatment groups.See, Table 22. The overall mean age was 44.1 years, and approximatelytwo-thirds (61.1%) of patients were women and most (83.3%) patients wereCaucasian. The mean age of MDD diagnosis was 27.5 years, indicating onaverage, a >15-year history of depression. The baseline MADRS, CGI-S andPHQ-9 scores were consistent with a population with TRD.

C. Efficacy

Efficacy was assessed by measuring response, remission and change inclinician-rated symptom severity. A patient was considered responsive ifthere was a ≥50% decrease in MADRS baseline score. A patient wasclassified to be “in remission” if the clinician-rated MADRS score was≤12 and the patient-rated PHQ-9 score was <5. Finally, a patient wasconsidered to have a change in clinician-rated symptom severity if therewas a ≥1-point decrease in the CGI-S and a ≥2-point decrease on theCGI-S.

Approximately 24-hours post dose (day 2), 11/43 (25.6%) patients in theESK+AD and 9/40 (22.5%) patients in the AD+PBO achieved a response.Responses at day 28 were 26/40 (65.0%) for patients in the ESK+AD vs15/38 (39.5%) in the AD+PBO group. See, FIG. 14. Similarly,approximately 24-hours post dose (day 2), 6/43 (14.0%) patients in theESK+PBO group and 4/40 (10.0%) patients in the AD+PBO group achievedclinician-rated remission.

Clinician-rated remission rates at day 28 were 18/40 (45.0%) patients inthe ESK+AD group and 9/38 (23.7%) patients in the AD+PBO group. See,FIG. 15.

The frequency distribution of PHQ-9 severity categories at day 15 andday 28 is shown in FIG. 16. At day 15, the percentage of patients withremission (i.e., score <5) was 11.4% in the ESK+AD group and 19.5% inthe AD+PBO group. At 4 weeks post-initial dose, the percentage ofpatients with remission (i.e., score <5) was 23.8% in the ESK+AD groupand 18.4% in the AD+PBO group. Further, at 4 weeks post-initial dose,the percentage of patients with severe depression (i.e., score 20-27),was more than 10-fold higher in the AD+PBO group (26.3%) than in theESK+AD group (2.4%).

Further, at day 4, a 21-point decrease in the CGI-S was observed innearly twice as many patients in the ESK+AD group compared with those inthe PBO+AD group (47.6 vs 26.3%); at day 28, the percentages were 77.5and 63.9%, respectively. See, FIG. 17. The percentage of patients with22-point decrease in the CGI-S was nearly 2-fold greater in the ESK+ADgroup compared with the PBO+AD group (14.3 vs 7.9%) at day 4; at day 28,the percentages were 52.5 vs 44.4%, respectively.

D. Safety

Safety was assessed via treatment emergent adverse events (TEAEs),serious AEs, vital signs, psychiatric symptoms as assessed by BriefPsychiatric Rating Scale (BPRS), dissociation as measured by ClinicianAdministered Dissociative States Scale (CADSS), and discharge readiness.See, Table 25B which shows the clinical global assessment of dischargereadiness which was assessed based on overall clinical states (includingsedation, perceptual changes, blood pressure, and other adverse events).

TABLE 25B Discharge Ready on each dosing day esketamine + oral AD + (%patients) Oral AD Nasal placebo 1 hour post dose ≥44.3% 92.0% 1.5 hourpost dose ≥93.2% 98.9%

Overall, TEAEs were observed in 91.3% of patients in the ESK+AD groupand 77.3% of patients in the AD+PBO group. See, Table 23. There were nodeaths. One patient in the ESK+AD group experienced a SAE during thefollow-up phase (cerebral hemorrhage on day 98). Four patients withdrewfrom the nasal spray drug (n=3 ESK; n=1 PBO), but no patients withdrewnew oral AD.

The most common TEAEs (25% in either treatment group) are shown in Table23. The incidence of TEAEs was similar between the US patients and theoverall study population. AEs observed during the study were mostly mildto moderate in severity and transient in nature.

As observed in the overall population, present-state dissociativesymptoms and transient perceptual effects as measured by the CADSS totalscore resolved spontaneously during the post dose observation periodprior to discharge (within 60-90 minutes post dose). Most (>90%)patients in each treatment group were ready for discharge by 1.5 hourspost dose. Vital sign and BPRS findings were consistent with the overallpopulation.

E. Conclusions

These results demonstrated that ESK+AD, compared with AD+PBO, provided arapid onset of effect that continued for 4 weeks and was generally welltolerated in US patients with TRD. These results also showed that thatESK+AD showed clinically meaningful improvements in depressive-symptomresponse and remission and had a favorable safety profile in US patientswith TRD. Specifically, ESK+AD demonstrated improvement inclinician-rated (CGI-S) and patient-rated (PHQ-9) assessments. Again,these observations agree with those from the overall study population,indicating that the US population has no significant differences inefficacy.

However, in the STAR-D level 3, which included patients with MDD who didnot remit with level 1 or level 2 treatment, the overall acute responserate (based on Quick Inventory of Depressive Symptomatology-Self Report,which was administered at each acute treatment clinic visit) was 16.8%and the overall acute remission rate was 13.7%. See, Rush, AmericanJournal of Psychiatry. 2006; 163(11):1905-1917 and Howland RH. Journalof Psychosocial Nursing and Mental Health Services. 2008; 46(10):21-24.By comparison, the response and remission rates observed with ESK+AD at4 weeks post-initial dose were much higher (45 and 65.0%, respectively,as assessed with MADRS).

Example 2 Efficacy of Intranasal Esketamine for Treating TreatmentResistance Depression (TRD) in Geriatric Patients, Phase 3 ClinicalTrial

The ability of esketamine to treat treatment-refractory ortreatment-resistant depression (TRD) was evaluated via the clinicalstudy described below, which was conducted to evaluate the efficacy,safety, and tolerability of flexibly dosed intranasal esketamine plus anewly initiated oral antidepressant in elderly subjects with TRD. Thestudy served as a pivotal Phase 3 short-term efficacy and safety studyin support of regulatory agency requirements for registration ofintranasal esketamine for the treatment of TRD. A diagram of the studydesign is provided in FIG. 18.

The hypothesis for this study was that, in elderly subjects with TRD,switching from a failed antidepressant treatment to intranasalesketamine plus a newly initiated oral antidepressant would be superiorto switching to a newly initiated oral antidepressant treatment (activecomparator) plus intranasal placebo in improving depressive symptoms.

The primary objective of this study was to evaluate the efficacy ofswitching elderly subjects with treatment-resistant depression (TRD)from a prior antidepressant treatment (to which they have not responded)to flexibly dosed intranasal esketamine (28 mg, 56 mg or 84 mg) plus anewly initiated oral antidepressant compared with switching to a newlyinitiated oral antidepressant plus intranasal placebo, in improvingdepressive symptoms, as assessed by the change from baseline in theMontgomery-Asberg Depression Rating Scale (MADRS) total score from Day 1(pre-randomization) to the end of the 4-week double-blind inductionphase.

The key secondary objectives were to assess the effect of intranasalesketamine plus a newly initiated oral antidepressant compared with anewly initiated oral antidepressant (active comparator) plus intranasalplacebo on the following parameters in elderly subjects with TRD: (a)Depressive symptoms (subject-reported), (b) Onset of clinical responseby Day 2, and (c) Functioning and associated disability. Additionalsecondary objectives included (a) Depression response rates, (b)Depression remission rates, (c) Overall severity of depressive illness,(d) Anxiety symptoms and (e) Health-related quality of life and healthstatus.

To investigate the safety and tolerability of intranasal esketamine plusa newly initiated oral antidepressant compared with a newly initiatedoral antidepressant (active comparator) plus intranasal placebo inelderly subjects with TRD, the following parameters were also measured:(a) TEAEs, including AEs of special interest, (b) Local nasaltolerability, (c) Effects on heart rate, blood pressure, respiratoryrate, and blood oxygen saturation, (d) Effects on alertness andsedation, (e) Potential psychosis-like effects, (f) Dissociativesymptoms, (g) Potential effects on cognitive function, (h) Potentialeffects on suicidal ideation/behavior, (i) Potential treatment-emergentsymptoms of cystitis and/or lower urinary tract symptoms, (j) Potentialwithdrawal and/or rebound symptoms following cessation of intranasalesketamine treatment, and (k) Potential effects on sense of smell.

Esketamine, the placebo solutions, and the oral antidepressantmedications were provided as described in Example 1 in “STUDY DRUGINFORMATION”.

Overview of Study Design

This was a randomized, double-blind, active-controlled, multicenterstudy that included 138 randomized elderly subjects with TRD. The studyhad 3 phases which are briefly described below.

The screening/prospective observational phase (4-week duration) was thesame as described in Example 1.

Double-Blind Induction Phase (4-Week Duration)

The study included 138 randomized subjects (one subject did not receiveany study drug (intranasal or oral AD) and is therefore not included inthe safety analysis and full analysis sets). The other 137 subjectsreceived both the intranasal and oral AD study drug and are included inthe full analysis set (FAS). The intranasal treatment sessions(esketamine or placebo) occurred twice weekly. In addition, all subjectsinitiated a new open-label oral antidepressant on Day 1 that was takendaily for the duration of this phase. The assigned oral antidepressantwas 1 of 4 oral antidepressant medications (duloxetine, escitalopram,sertraline, or venlafaxine extended release [XR]), that the subject hadnot previously had a nonresponse to in the current depressive episode,had not been previously intolerant to (lifetime), and was available inthe participating country.

At the end of the induction phase, subjects who were responders (definedas ≥50% reduction in the MADRS total score from baseline [Day 1pre-randomization] to the end of the 4-week double-blind inductionphase) were eligible to participate in the subsequent studyESKETINTRD3003 if they met all other study entry criteria(ESKETINTRD3003 is a longer-term efficacy maintenance study involvingrepeated treatment sessions of intranasal esketamine).

If a subject withdrew from the study before the end of the double-blindinduction phase for reasons other than withdrawal of consent, an EarlyWithdrawal visit was conducted within 1 week of the date ofdiscontinuation, followed by the follow-up phase.

The Follow-Up Phase (24-Week Duration) was the Same as Described inExample 1. Study Population

The inclusion and exclusion criteria for enrolling subjects in thisstudy were as described in Example 1 under “Study Population” with theexception that at the time of signing the informed consent form (ICF),the subject was a man or woman ≥65 years of age, inclusive. Eachpotential subject satisfied all of the criteria to be enrolled in thestudy.

Additionally, potential subjects had to be willing and able to adhere tothe prohibitions and restrictions as described in Example 1 under “StudyPopulation”.

Treatment Allocation, Randomization and Blinding

The treatment allocation, randomization and blinding was performed asdescribed in Example 1.

In the FAS, 130/137 (94.9%) of the subjects were white and 85/137(62.0%) of the subjects were female. The mean age was 70.0 years,ranging from 65 to 86 years. Out of 138 subjects in the all randomizedanalysis set, 122 (88.4%) completed the double-blind phase and 16withdrew early, of which 6 withdrew due to ‘adverse events’, 3 due to‘withdrawal by subject’, 4 due to ‘lack of efficacy’, 1 for ‘loss tofollow-up’, 1 due to protocol violation and 1 due to ‘other’ reasons.Subsequently, 15 subjects entered the follow-up phase, 111 subjectscontinued into the ESKETINTRD3004 study and 2 subjects continued to54135419TRD3008.

Subject and Treatment Information

A total of 302 subjects were screened across 57 sites in 13 countries(Belgium, Brazil, Bulgaria, Finland, France, Italy, Lithuania, Poland,South Africa, Spain, Sweden, UK and the US). Excluding 3 subjects from aUS site due to GCP issues, 138 subjects with a DSM-5 (Diagnostic andStatistical Manual of Mental Disorders, 5th Edition) diagnosis of MDD(aged 65 or older) were randomized to two groups in a ratio of 1:1 (72in intranasal esketamine plus oral AD and 66 in oral AD plus intranasalplacebo).

Of the 138 randomized subjects, 1 subject did not receive any study drug(intranasal or oral AD) and are therefore not included in the safetyanalysis and full analysis sets. The other 137 subjects received boththe intranasal and oral AD study drug and are included in the fullanalysis set.

TABLE 26 Number of Subjects in Each Analysis Set (Study ESKETINTRD3005:All Randomized Analysis Set) Intranasal Esk + Oral AD + Oral ADIntranasal Placebo Total (N = 72) (N = 66) (N = 138) All randomized 72(100.0%)  66 (100.0%)  138 (100.0%) Full 72 (100.0%) 65 (98.5%) 137(99.3%) Safety 72 (100.0%) 65 (98.5%) 137 (99.3%) Follow-up 12 (16.7%) 3 (4.5%)  15 (10.9%)

Of the 138 randomized subjects, 122 (88.4%) subjects completed the28-day double-blind induction phase. Results are presented in Table 27.The most frequent reason for withdrawal was adverse event. Subsequently,15 subjects entered the follow-up phase, 111 subjects continued into theESKETINTRD3004 study and 2 subjects continued to 54135419TRD3008 afterESKETINTRD3004 was dosed.

TABLE 27 Study Completion/Withdrawal Information; Double-blind InductionPhase (Study ESKETINTRD3005: All Randomized Analysis Set) IntranasalEsk + Oral AD + Oral AD Intranasal Placebo Total (N = 72) (N = 66) (N =138) Completed 62 (86.1%) 60 (90.9%) 122 (88.4%)  Withdrawn 10 (13.9%) 6(9.1%) 16 (11.6%) Adverse event 4 (5.6%) 2 (3.0%) 6 (4.3%) Lack ofefficacy 3 (4.2%) 1 (1.5%) 4 (2.9%) Lost to follow-up 1 (1.4%) 0 1(0.7%) Protocol violation 0 1 (1.5%) 1 (0.7%) Withdrawal by 1 (1.4%) 2(3.0%) 3 (2.2%) subject Other 1 (1.4%) 0 1 (0.7%)

Demographic and baseline characteristics are displayed in Table 28 forthe full analysis set. In general, the treatment groups were similarwith respect to the baseline characteristics. The majority of subjectsentering the study were female (62.0%). The mean (SD) age of allsubjects was 70.0 (4.52) years, ranging from 65 to 86 years. See, FIG.26.

TABLE 28 Demographic and Baseline Characteristics (Study ESKETINTRD3005:Full Analysis Set) Intranasal Esk + Oral AD + Oral AD Intranasal PlaceboTotal (N = 72) (N = 65) (N = 137) Age (years) N 72 65 137 Mean (SD) 70.6(4.79) 69.4 (4.15) 70.0 (4.52) Median 70.0 68.0 69.0 Range (65; 86) (65;82) (65; 86) Age category (years), n (%) N 72 65 137 65-74 59 (81.9%) 57(87.7%) 116 (84.7%) ≥75 13 (18.1%) 8 (12.3%) 21 (15.3%) Sex, n (%) N 7265 137 Male 27 (37.5%) 25 (38.5%) 52 (38.0%) Female 45 (62.5%) 40(61.5%) 85 (62.0%) Race, n (%) N 72 65 137 White 66 (91.7%) 64 (98.5%)130 (94.9%) Multiple 4 (5.6%) 0 4 (2.9%) Not Reported 1 (1.4%) 1 (1.5%)2 (1.5%) Unknown 1 (1.4%) 0 1 (0.7%) Ethnicity, n (%) N 72 65 137Hispanic or Latino 10 (13.9%) 5 (7.7%) 15 (10.9%) Not Hispanic or Latino59 (81.9%) 59 (90.8%) 118 (86.1%) Not Reported 2 (2.8%) 1 (1.5%) 3(2.2%) Unknown 1 (1.4%) 0 1 (0.7%) Baseline weight (kg) N 72 65 137 Mean(SD) 78.44 (16.665) 81.70 (18.948) 79.99 (17.794) Median 76.25 77.6077.50 Range  (44.0; 113.5)  (43.0; 134.8)  (43.0; 134.8) Baseline height(cm) N 72 65 137 Mean (SD) 165.46 (10.951) 166.79 (10.346) 166.09(10.650) Median 162.80 165.00 164.00 Range (139.7; 191.0) (149.9; 193.0)(139.7; 193.0) Baseline body mass index (kg/m2) N 72 65 137 Mean (SD)28.6 (5.17) 29.3 (6.14) 28.9 (5.64) Median 27.6 28.3 27.8 Range (20; 45)(16; 45) (16; 45) BMI category (kg/m²), n (%) N 72 65 137 Underweight<18.5 0 1 (1.5%) 1 (0.7%) Normal 18.5-<25 18 (25.0%) 14 (21.5%) 32(23.4%) Overweight 25-<30 28 (38.9%) 21 (32.3%) 49 (35.8%) Obese 30-<4023 (31.9%) 24 (36.9%) 47 (34.3%) Morbidly obese ≥40 3 (4.2%) 5 (7.7%) 8(5.8%) Employment status, n (%) ^(a) N 72 65 137 Any type of employment11 (15.3%) 13 (20.0%) 24 (17.5%) Any type of unemployment 2 (2.8%) 6(9.2%) 8 (5.8%) Other 59 (81.9%) 46 (70.8%) 105 (76.6%) Hypertensionstatus, n (%) ^(b) N 72 65 137 Yes 41 (56.9%) 32 (49.2%) 73 (53.3%) No31 (43.1%) 33 (50.8%) 64 (46.7%) Country, n (%) N 72 65 137 Belgium 2(2.8%) 4 (6.2%) 6 (4.4%) Brazil 1 (1.4%) 0 1 (0.7%) Bulgaria 3 (4.2%) 03 (2.2%) Finland 1 (1.4%) 1 (1.5%) 2 (1.5%) France 4 (5.6%) 3 (4.6%) 7(5.1%) Italy 6 (8.3%) 3 (4.6%) 9 (6.6%) Lithuania 2 (2.8%) 0 2 (1.5%)Poland 4 (5.6%) 3 (4.6%) 7 (5.1%) South Africa 2 (2.8%) 5 (7.7%) 7(5.1%) Spain 4 (5.6%) 4 (6.2%) 8 (5.8%) Sweden 8 (11.1%) 6 (9.2%) 14(10.2%) United Kingdom 1 (1.4%) 0 1 (0.7%) United States 34 (47.2%) 36(55.4%) 70 (51.1%) Region, n (%) N 72 65 137 Europe 35 (48.6%) 24(36.9%) 59 (43.1%) North America 34 (47.2%) 36 (55.4%) 70 (51.1%) Other3 (4.2%) 5 (7.7%) 8 (5.8%) Class of oral antidepressant, n (%) N 72 65137 SNRI 31 (43.1%) 30 (46.2%) 61 (44.5%) SSRI 41 (56.9%) 35 (53.8%) 76(55.5%) Oral antidepressant, n (%) N 72 65 137 Duloxetine 25 (34.7%) 23(35.4%) 48 (35.0%) Escitalopram 25 (34.7%) 25 (38.5%) 50 (36.5%)Sertraline 15 (20.8%) 10 (15.4%) 25 (18.2%) Venlafaxine extended release(XR) 7 (9.7%) 7 (10.8%) 14 (10.2%) ^(a) Any type of employment includes:any category containing “Employed”, Sheltered Work, Housewife orDependent Husband, and Student; any type of unemployment includes: anycategory containing “Unemployed”; Other includes: Retired and NoInformation Available. ^(b) Hypertension status is classified as Yes ifhypertension is recorded in medical history.

Baseline psychiatric history for the full analysis set is presented inTable 29. The mean (SD) baseline MADRS total score was 35.2 (6.16),ranging from 19 to 51. 84.7% of subjects documented non-response to 2 ormore antidepressant treatments taken for at least 6 weeks on theMGH-ATRQ at screening. The remaining 15.3% subjects documentednon-response to 1 antidepressant at screening, and non-response to asecond antidepressant was confirmed prospectively during thescreening/prospective observational phase.

TABLE 29 Baseline Psychiatric History (Study ESKETINTRD3005: FullAnalysis Set) Intranasal Esk + Oral AD + Oral AD Intranasal PlaceboTotal (N = 72) (N = 65) (N = 137) Age when diagnosed with MDD (years) N72 65 137 Mean (SD) 42.6 (16.18) 43.7 (16.28) 43.1 (16.18) Median 43.045.0 44.0 Range (10; 75) (11; 77) (10; 77) Baseline MADRS total score N72 65 137 Mean (SD) 35.5 (5.91) 34.8 (6.44) 35.2 (6.16) Median 36.0 35.036.0 Range (23; 50) (19; 51) (19; 51) Screening IDS-C30 total score N 7163 134 Mean (SD) 44.2 (6.50) 43.1 (6.71) 43.7 (6.60) Median 45.0 43.044.0 Range (33; 60) (31; 67) (31; 67) Baseline CGI-S N 72 65 137 Mean(SD) 5.1 (0.76) 4.8 (0.80) 5.0 (0.79) Median 5.0 5.0 5.0 Range (3; 7)(3; 6) (3; 7) Baseline CGI-S category, n (%) N 72 65 137 Normal, not atall ill 0 0 0 Borderline mentally ill 0 0 0 Mildly ill 2 (2.8%) 2 (3.1%)4 (2.9%) Moderately ill 10 (13.9%) 20 (30.8%) 30 (21.9%) Markedly ill 39(54.2%) 29 (44.6%) 68 (49.6%) Severely ill 20 (27.8%) 14 (21.5%) 34(24.8%) Among the most extremely ill patients 1 (1.4%) 0 1 (0.7%)Baseline PHQ-9 total score N 72 65 137 Mean (SD) 17.6 (4.99) 17.4 (6.33)17.5 (5.65) Median 19.0 18.0 19.0 Range  (2; 27)  (0; 27)  (0; 27)Screening C-SSRS lifetime ^(a), n (%) N 70 64 134 No event 38 (54.3%) 34(53.1%) 72 (53.7%) Suicidal ideation 24 (34.3%) 19 (29.7%) 43 (32.1%)Suicidal behavior 8 (11.4%) 11 (17.2%) 19 (14.2%) Screening C-SSRS past6 or 12 months ^(a), n (%) N 70 64 134 No event 42 (60.0%) 43 (67.2%) 85(63.4%) Suicidal ideation (past 6 months) 28 (40.0%) 20 (31.3%) 48(35.8%) Suicidal behavior (past 12 months) 0 1 (1.6%) 1 (0.7%) Durationof current episode (wks) N 72 65 137 Mean (SD) 163.1 (277.04) 274.1(395.47) 215.8 (341.71) Median 83.5 104.0 92.0 Range   (8; 1700)   (8;2184)   (8; 2184) No. of previous antidepressant medications ^(b), n (%)N 72 65 137 1 15 (20.8%) 6 (9.2%) 21 (15.3%) 2 31 (43.1%) 32 (49.2%) 63(46.0%) 3 13 (18.1%) 17 (26.2%) 30 (21.9%) 4 12 (16.7%) 4 (6.2%) 16(11.7%) 5 1 (1.4%) 4 (6.2%) 5 (3.6%) 7 0 1 (1.5%) 1 (0.7%) 8 0 1 (1.5%)1 (0.7%) Family history of depression, n (%) N 72 65 137 Yes 30 (41.7%)26 (40.0%) 56 (40.9%) No 42 (58.3%) 39 (60.0%) 81 (59.1%) Family historyof anxiety disorder, n (%) N 72 65 137 Yes 6 (8.3%) 5 (7.7%) 11 (8.0%)No 66 (91.7%) 60 (92.3%) 126 (92.0%) Family history of bipolar disorder,n (%) N 72 65 137 Yes 3 (4.2%) 4 (6.2%) 7 (5.1%) No 69 (95.8%) 61(93.8%) 130 (94.9%) Family history of schizophrenia, n (%) N 72 65 137Yes 2 (2.8%) 4 (6.2%) 6 (4.4%) No 70 (97.2%) 61 (93.8%) 131 (95.6%)Family history of alcohol abuse, n (%) N 72 65 137 Yes 3 (4.2%) 7(10.8%) 10 (7.3%) No 69 (95.8%) 58 (89.2%) 127 (92.7%) Family history ofsubstance abuse, n (%) N 72 65 137 Yes 1 (1.4%) 0 1 (0.7%) No 71 (98.6%)65 (100.0%) 136 (99.3%) ^(a) C-SSRS category: No event = 0; Suicidalideation = 1, 2, 3, 4, 5; Suicidal behavior = 6, 7, 8, 9, 10; ^(b)Number of antidepressant medications with non-response (defined as ≤25%improvement) taken for at least 6 weeks during the current episode asobtained from MGH-ATRQ.

Dosage and Administration

Screening/Prospective Observational Phase: The Screening/ProspectiveObservational Phase was the same as that described in Example 1.Double-Blind Induction Phase: The double-blind induction phase was thesame as that described in Example 1.Intranasal Study Drug: The intranasal study drug was the same as thatdescribed in Example 1. See, Table 4.Oral Antidepressant Medication: The oral antidepressant medicationtreatment was the same as that described in Example 1. See, Table 5.Guidance on Blood Pressure Monitoring on Intranasal Dosing Days: Theguidance on blood pressure monitoring on intranasal dosing days was thesame as described in Example 1.Follow-up Phase: The follow-up phase was the same as that described inExample 1.Treatment Compliance: The treatment compliance was the same as thatdescribed in Example 1.Pre-Study and Concomitant Therapy: The pre-study and concomitant therapywas the same as that described in Example 1.Rescue Medications: Rescue medication use is described in Example 1.Prohibited Medications: A list of prohibited medications is the same asthose listed in Table 6 of Example 1.

The number of doses of intranasal study medication was the same asdescribed in Table 7 of Example 1.

A summary of mean, mode and final dose of intranasal study medication issummarized in Table 30. On Day 15 of the Double-blind Induction phase49/65 (75.4%) were receiving the 84 mg dose of esketamine. Of the 72subjects treated with intranasal esketamine, 17 (23.6%) of subjectsdecreased their dose during the double-blind phase.

TABLE 30 Mean, Mode, and Final Daily Dose of Intranasal StudyMedication; Double-blind Induction Phase Study ESKETINTRD3005: SafetyAnalysis Set) Intranasal Esk + Oral AD (N = 72) Mean daily dose (mg) N72 Mean (SD) 59.8 (15.40) Median   66.5 Range (28; 74) Mode daily dose(mg) N 71 Mean (SD) 68.6 (22.09) Median   84.0 Range (28; 84) Finaldaily dose (mg) N 72 Mean (SD) 68.1 (21.45) Median   84.0 Range (28; 84)The calculation of mean, mode, and final daily dose excludes days offintranasal study medication. The final dose is the last non-zero dosereceived during the double-blind induction phase.

A summary of mean, mode and final dose of oral AD by each type of oralAD is summarized in Table 31.

TABLE 31 Mean, Mode and Final Daily Dose of Oral Antidepressant;Double-blind Induction Phase (Study ESKETINTRD3005: Safety Analysis Set)Intranasal Esk + Oral AD + Oral AD Intranasal Placebo (N = 72) (N = 65)Duloxetine Mean daily dose (mg) N 25 23 Mean (SD) 49.8 (7.42) 50.3(7.65) Median   52.2   52.2 Range (30; 60) (30; 60)  Mode daily dose(mg) N 25 23 Mean (SD) 52.8 (13.08) 56.1 (10.33) Median   60.0   60.0Range (30; 60) (30; 60)  Final daily dose (mg) N 25 23 Mean (SD) 57.6(8.31) 57.4 (8.64) Median   60.0   60.0 Range (30; 60) (30; 60) Escitalopram Mean daily dose (mg) N 25 25 Mean (SD) 10.2 (0.89) 9.9(0.58) Median   10.0   10.0 Range (10; 14) (7; 10) Mode daily dose (mg)N 25 25 Mean (SD) 10.2 (1.00) 9.8 (1.00) Median   10.0   10.0 Range (10;15) (5; 10) Final daily dose (mg) N 25 25 Mean (SD) 10.2 (1.00) 9.8(1.00) Median   10.0   10.0 Range (10; 15) (5; 10) Sertraline Mean dailydose (mg) N 15 10 Mean (SD) 70.7 (18.54) 80.6 (18.70) Median   74.1  82.4 Range  (40; 100) (38; 108) Mode daily dose (mg) N 15 10 Mean (SD)81.7 (49.52) 90.0 (55.53) Median   50.0   75.0 Range  (25; 150) (25;150) Final daily dose (mg) N 15 10 Mean (SD) 110.0 (42.05) 127.5 (41.58)Median  100.0  150.0 Range  (50; 150) (25; 150) Venlafaxine XR Meandaily dose (mg) N  7  8 Mean (SD) 92.7 (29.05) 86.3 (29.60) Median 102.2   94.1 Range  (49; 140) (38; 131) Mode daily dose (mg) N  7  8Mean (SD) 112.5 (48.41) 107.8 (46.74) Median  150.0  112.5 Range  (38;150) (38; 150) Final daily dose (mg) N  7  8 Mean (SD) 117.9 (40.09)117.2 (46.74) Median  150.0  150.0 Range  (75; 150) (38; 150) Thecalculation of mean, mode, and final daily dose excludes days off oralantidepressant. The final dose is the last non-zero dose received duringthe double-blind induction phase.

Duration of exposure to oral antidepressant study medication isSummarized in Table 32 and 33.

TABLE 32 Extent of Exposure to Oral Antidepressant; Double-blindInduction Phase (Study ESKETINTRD3005: Safety Analysis Set) Serotoninand Norepinephrine Reuptake Inhibitors (SNRI) Duloxetine Venlafaxine XRTotal Intranasal esk + (N = 25) (N = 7) (N = 32) oral AD Total duration,days Category, n (%)  ≤7 1 (4.0%) 0 1 (3.1%)  8-14 2 (8.0%) 0 2 (6.3%)15-21 1 (4.0%) 2 (28.6%) 3 (9.4%) 22-28 12 (48.0%) 2 (28.6%) 14(43.8%) >28 9 (36.0%) 3 (42.9%) 12 (37.5%) Mean (SD) 25.6 (6.70) 25.6(5.32) 25.6 (6.34) Median 27.0  28.0 28.0 Range (5; 31) (16; 29) (5; 31)Oral AD + (N = 23) (N = 8) (N = 31) intranasal placebo Total duration,days Category, n (%)  ≤7 1 (4.3%) 1 (12.5%) 2 (6.5%)  8-14 0  0 0  15-211 (4.3%) 0 1 (3.2%) 22-28 9 (39.1%) 5 (62.5%) 14 (45.2%) >28 12 (52.2%)2 (25.0%) 14 (45.2%) Mean (SD) 27.2 (5.52) 26.3 (8.31) 26.9 (6.22)Median 29.0  28.0 28.0 Range (5; 35)  (7; 36) (5; 36) Percentages arecalculated with the number of subjects in each treatment group as thedenominator. The duration of exposure is defined as the duration betweenthe date of the first antidepressant exposure and the date of the lastantidepressant exposure. It includes days on which subjects did notactually take medication.

TABLE 33 Extent of Exposure to Oral Antidepressant; Double-blindInduction Phase (Study ESKETINTRD3005: Safety Analysis Set) SelectiveSerotonin Reuptake Inhibitors (SSRI) Escitalopram Sertraline TotalIntranasal esk + (N = 25) (N = 15) (N = 40) oral AD Total duration, daysCategory, n (%)  ≤7 0 0 0  8-14 0 0 0 15-21 0 1 (6.7%) 1 (2.5%) 22-28 11(44.0%) 7 (46.7%) 18 (45.0%) >28 14 (56.0%) 7 (46.7%) 21 (52.5%) Mean(SD) 28.9 (2.14) 28.0 (2.39) 28.6 (2.25) Median 29.0 28.0 29.0 Range(26; 37) (21; 32) (21; 37) Oral AD + (N = 25) (N = 10) (N = 35)intranasal placebo Total duration, days Category, n (%)  ≤7 0 0 0  8-141 (4.0%) 0 1 (2.9%) 15-21 1 (4.0%) 1 (10.0%) 2 (5.7%) 22-28 11 (44.0%) 5(50.0%) 16 (45.7%) >28 12 (48.0%) 4 (40.0%) 16 (45.7%) Mean (SD) 27.8(4.93) 31.2 (9.47) 28.7 (6.59) Median  28.0 28.0 28.0 Range (11; 35)(20; 49) (11; 49) Percentages are calculated with the number of subjectsin each treatment group as the denominator. The duration of exposure isdefined as the duration between the date of the first antidepressantexposure and the date of the last antidepressant exposure. It includesdays on which subjects did not actually take medication.

Study Evaluations

The study evaluations were performed as described in Example 1. The timeand events schedule was the same as described in Example 1 in Tables 10and 11. The approximate total blood volume to be collected from eachsubject was the same as described in Example 1. See, Table 12.

Screening/Prospective Observational Phase

The screening/prospective observational phase was the same as describedin Example 1. After signing the ICF, subjects who were 2:65 years of age(inclusive) were screened to determine eligibility for studyparticipation.

Optional Antidepressant Taper Period: The optional antidepressant taperperiod was performed as described in Example 1.Double-Blind Induction Phase: The double-blind induction phase wasperformed as described in Example 1.Early Withdrawal: The early withdrawal of patient was followed accordingto the procedure in Example 1.Follow-up Phase: The follow-up phase was performed as described inExample 1.

Efficacy Evaluations

Efficacy evaluations were performed as described in Example 1.

Primary Efficacy Evaluation: The primary efficacy evaluation isdescribed in Example 1.Key Secondary Efficacy Evaluation (Clinician-completed): The keysecondary efficacy evaluation (clinician-completed) is described inExample 1.Key Secondary Efficacy Evaluation (Patient-reported Outcome): The keysecondary efficacy evaluation (patient-reported outcome) is described inExample 1.Primary Endpoint: The primary efficacy endpoint is described in Example1.Primary Endpoint Results: The primary endpoint results are the same asdescribed in Example 1. See, Table 34 and FIG. 19.

TABLE 34 MADRS Total Score: Change From Baseline to Day 28 MMRM;Double-blind Induction Phase (Study ESKETINTRD3005: Full Analysis Set)Intranasal Esk + Oral AD + Oral AD Intranasal Placebo (N = 72) (N = 65)Baseline N 72 65 Mean (SD) 35.5 (5.91) 34.8 (6.44) Median (Range) 36.0(23; 50) 35.0 (19; 51) Day 28 N 63 60 Mean (SD) 25.4 (12.70) 28.7(10.11) Median (Range) 25.0 (0; 47) 30.0 (2; 44) Change from baseline today 28 N 63 60 Mean (SD) −10.0 (12.74) −6.3 (8.86) Median (Range) −5.0(−42; 10) −4.5 (−33; 11) MMRM analysis ^(a) Diff. of LS means (Esk + AD −3.6 minus AD + Placebo) ^(b) 95% confidence interval on diff. ^(c)−7.20; 0.07 1-sided p-value ^(d) 0.029 NS ^(a) Test for treatment effectis based on mixed model for repeated measures (MMRM) with change frombaseline as the response variable and the fixed effect model terms fortreatment (intranasal esk + oral AD, oral AD + intranasal placebo), day,region, class of oral antidepressant (SNRI or SSRI), andtreatment-by-day, and baseline value as a covariate. A negativedifference favors esketamine. ^(b) Difference from placebo is the medianunbiased estimate, which is a weighted combination of the least squaresmeans of the difference from placebo ^(c) 2-sided flexible confidenceinterval ^(d) P-value is based on the weighted combination teststatistics MADRS Total score ranges from 0 to 60; a higher scoreindicates a more severe condition. Negative change in score indicatesimprovement.

FIG. 23 shows the least square mean changes (t) from baseline for theMADRS total score over time in the double-blind phase based on the MMRManalysis. This data shows that, when compared to a younger population, alonger induction period is required to achieve the desired response.See, FIG. 2 which shows the response for the corresponding youngerpopulation (-▴-).

Secondary Endpoints: The secondary endpoints were the same as describedin Example 1.

Subgroup Analyses

A forest plot showing the treatment differences based on an MMRManalysis for the preplanned subgroups are shown in FIG. 24. There was anotable difference by age subgroup. The arithmetic mean changes overtime for the MADRS total score are presented by age group in FIGS. 25and 26. The difference in LS mean change (SE) based on the MMRM analysisat Day 28 was −4.9 (2.04) for subjects aged 65-74 and −0.4 (5.02) forsubjects aged 75 and above. However, the number of subjects in thehigher age group was low.

Post-Hoc Analyses for Primary Endpoint

As specified in the SAP, the weighted combination test was the primaryanalysis for the primary efficacy endpoint since an interim analysis forsample size re-estimation was conducted. A post-hoc analysis using anunweighted MMRM analysis (essentially disregarding the interim analysis)was performed and the one-sided p-value was 0.018 using this approach.The post-hoc one-sided p-value was 0.017 using the unweighted ANCOVAanalysis.

In addition, a treatment by stage (before and after IA was performed)interaction was explored. A differential treatment effect was seen forStage 1 (those subjects enrolled prior to when the IA was performed) andStage 2 (those subjects enrolled after the IA was performed). The LSmean (SE) treatment difference was −1.6 (2.62) for Stage 1 and −5.6(2.63) for Stage 2. See, FIG. 27 (Stage 1) and FIG. 28 (Stage 2) for theLS mean changes over time for each treatment group.

Response and Remission Rates Based on MADRS Total Score

Response (≥50% improvement from baseline in the MADRS total score) andRemission (MADRS total score is ≤12) rates are presented in Table 35.

TABLE 35 Response and Remission Rates Based on MADRS; Double-blindInduction Phase (Study ESKETINTRD3005: Full Analysis Set) ResponseRemission Intranasal Oral AD + Intranasal Oral AD + Esk + IntranasalEsk + Intranasal Oral AD Placebo Oral AD Placebo Day 8 4/66 (6.1%) 3/63(4.8%)  4/66 (6.1%) 1/63 (1.6%) Day 15 4/68 (5.9%) 8/62 (12.9%) 2/68(2.9%) 5/62 (8.1%) Day 22  9/60 (15.0%) 8/56 (14.3%) 4/60 (6.7%) 4/56(7.1%) Day 28 17/63 (27.0%) 8/60 (13.3%) 11/63 (17.5%) 4/60 (6.7%) Asubject is defined as a responder at a given time point if the percentimprovement from baseline in MADRS total score is at least 50%. Asubject is in remission at a given time point if the MADRS total scoreis ≤12.

The response rates (≥50% improvement from baseline) at Day 28 based onthe MADRS total score were 17/63 (27.0%) and 8/60 (13.3%) for theintranasal esketamine+oral AD and oral AD+ intranasal placebo groups,respectively. The remission rates (MADRS total score ≤12) at Day 28 were11/63 (17.5%) and 4/60 (6.7%) for the intranasal esketamine+oral AD andoral AD+ intranasal placebo groups, respectively.

Safety Evaluations: Safety evaluations were performed as described inExample 1.Adverse Events: Adverse events were followed as described in Example 1.Clinical Laboratory Tests: Clinical laboratory tests were performed asdescribed in Example 1.

Subject Completion/Withdrawal Completion

A subject was considered to have completed the double-blind inductionphase of the study if he or she completed the MADRS assessment at theend of the 4-week double-blind induction phase (i.e., Day 28 MADRS) asdescribed in Example 1.

Withdrawal from the Study: A subject was withdrawn from the study forany of the nine reasons provided in Example 1.Safety Analyses: Safety data was analyzed for the double-blind inductionphase using the safety analysis set.Adverse Events: The verbatim terms used in the eCRF by investigators toidentify adverse events were coded using the MedDRA as described inExample 1.Clinical Laboratory Tests: Clinical laboratory tests were performed asdescribed in Example 1.ECG: The effects on cardiovascular variables were evaluated by means ofdescriptive statistics and frequency tabulations. These tables includeobserved values and change from baseline values. Electrocardiogram datawas summarized by ECG parameter as described in Example 1.Vital Signs: Vital signs were obtained as described in Example 1.Nasal Examination: Nasal examinations were performed as described inExample 1.Nasal Symptom Questionnaire: Scoring from the nasal symptomquestionnaire was summarized descriptively for each scheduled time pointby treatment group as described in Example 1.C-SSRS: Suicide-related thoughts and behaviors based on the C-SSRS weresummarized by treatment group in incidence and shift tables as describedin Example 1. Separate endpoints for suicidal ideation and suicidalbehavior were defined and summarized descriptively by treatment group.Missing scores were not imputed.CADSS, BPRS+, and MOAA/S: Descriptive statistics of each score andchanges from pre-dose were summarized at each scheduled time point asdescribed in Example 1.

Clinical Global Assessment of Discharge Readiness, PWC-20, BPIC-SS,UPSIT, and Smell Threshold Test

Descriptive statistics of each score and changes and/or percent changesfrom baseline were summarized at each scheduled time point as describedin Example 1.

Cognition Testing: Descriptive statistics of the cognitive domain scoresand changes from baseline were summarized at each scheduled time point.Adverse Event Definitions and Classifications: Adverse event definitionsand classifications were performed as described in Example 1.Special Reporting Situations: Special reporting situations werediscussed in Example 1

Procedures: All Adverse Events

All adverse events and special reporting situations, whether serious ornon-serious, were reported from the time a signed and dated ICF wasobtained until completion of the subject's last study-related procedure(which may include contact for follow-up of safety) as described inExample 1.

Serious Adverse Events: Serious adverse event studies were performed asdescribed in Example 1.Pregnancy: Pregnancy was assessed as described in Example 1.

Summary of all Adverse Events

An overall summary of all treatment-emergent adverse events (TEAEs)during the double-blind phase is presented in Table 36. Overall, 70.8%of subjects in the esketamine+oral AD group and 60.0% of subjects in theoral AD+placebo group experienced at least one TEAE during thedouble-blind phase.

TABLE 36 Overall Summary of Treatment-emergent Adverse Events (TEAE);Double-blind Induction Phase (Study ESKETINTRD3005: Safety Analysis Set)Intranasal Esk + Oral AD + Oral AD Intranasal Placebo (N = 72) (N = 65)TEAE 51 (70.8%) 39 (60.0%) TEAE possibly related to intranasal 42(58.3%) 22 (33.8%) drug ^(a) TEAE possibly related to oral 13 (18.1%) 11(16.9%) antidepressant ^(a) TEAE leading to death 0 0 1 or more seriousTEAE 3 (4.2%) 2 (3.1%) TEAE leading to intranasal drug 4 (5.6%) 2 (3.1%)withdrawn ^(b) TEAE leading to oral 1 (1.4%) 1 (1.5%) antidepressantwithdrawn ^(b) ^(a) Study drug relationships of possible, probable, andvery likely are included in this category. ^(b) An adverse event thatstarted in the double-blind induction phase and resulted indiscontinuation in the follow-up phase is counted as treatment-emergentin the double-blind induction phase. Incidence is based on the number ofsubjects experiencing at least one adverse event, not the number ofevents. Adverse events are coded using MedDRA version 20.0.

Treatment-emergent adverse events occurring during the double-blindphase (>5% of subjects in either treatment group) are summarized bytreatment group for the safety analysis set in Table 37. The most common(>10%) TEAEs in the esketamine+oral AD group during the double-blindphase were dizziness (20.8%), nausea (18.1%), headache (12.5%), fatigue(12.5%), blood pressure increased (12.5%), vertigo (11.1%) anddissociation (11.1%). The most common TEAE in the oral AD+placebo groupwere anxiety (7.7%), dizziness (7.7%) and fatigue (7.7%). There were nodeaths.

TABLE 37 Treatment-emergent Adverse Events in at Least 5% of Subjects inEither Treatment Group; Double-blind Induction Phase (StudyESKETINTRD3005: Safety Analysis Set) Intranasal Esk + Oral AD + Oral ADIntranasal Placebo (N = 72) (N = 65) Total no. subjects with TEAE 51(70.8%) 39 (60.0%) Psychiatric disorders 26 (36.1%) 11 (16.9%)Dissociation 8 (11.1%) 1 (1.5%) Dysphoria 4 (5.6%) 0 Insomnia 4 (5.6%) 3(4.6%) Anxiety 2 (2.8%) 5 (7.7%) Nervous system disorders 24 (33.3%) 15(23.1%) Dizziness 15 (20.8%) 5 (7.7%) Headache 9 (12.5%) 2 (3.1%)Dysgeusia 4 (5.6%) 3 (4.6%) Hypoesthesia 4 (5.6%) 1 (1.5%) Paresthesia 4(5.6%) 2 (3.1%) Gastrointestinal disorders 19 (26.4%) 8 (12.3%) Nausea13 (18.1%) 3 (4.6%) Hypoesthesia oral 5 (6.9%) 0 Vomiting 5 (6.9%) 1(1.5%) General disorders and 14 (19.4%) 9 (13.8%) administration siteconditions Fatigue 9 (12.5%) 5 (7.7%) Investigations 14 (19.4%) 6 (9.2%)Blood pressure increased 9 (12.5%) 3 (4.6%) Ear and labyrinth disorders10 (13.9%) 4 (6.2%) Vertigo 8 (11.1%) 2 (3.1%) Infections andinfestations 8 (11.1%) 6 (9.2%) Urinary tract infection 6 (8.3%) 1(1.5%) Incidence is based on the number of subjects experiencing atleast one adverse event, not the number of events. Adverse events arecoded using MedDRA version 20.0.

Adverse Events Leading to Study Drug Withdrawal

There were 6 subjects (4 subjects in the esketamine+oral AD group and 2subject in the oral AD+placebo group) who discontinued the double-blindinduction phase intranasal study medication due to treatment-emergentadverse events. See, Table 19. There were 2 subjects (1 subject in theesketamine+oral AD group and 1 subject in the oral AD+placebo group) whodiscontinued the double-blind phase due to TEAEs. See, Tables 38 and 39.

TABLE 38 Treatment-emergent Adverse Events Leading to Discontinuation ofIntranasal Study Medication; Double-blind Induction Phase (StudyESKETINTRD3005: Safety Analysis Set) Intranasal Esk + Oral AD + Oral ADIntranasal Placebo (N = 72) (N = 65) Total no. subjects with TEAE 4(5.6%) 2 (3.1%) leading to discontinuation ^(a) Investigations 2 (2.8%)0 Blood pressure increased 1 (1.4%) 0 Blood pressure systolic increased1 (1.4%) 0 Injury, poisoning and procedural 1 (1.4%) 0 complications Hipfracture 1 (1.4%) 0 Psychiatric disorders 1 (1.4%) 1 (1.5%) Anxietydisorder 1 (1.4%) 0 Anxiety 0 1 (1.5%) Feeling of despair 0 1 (1.5%) Eyedisorders 0 1 (1.5%) Dry eye 0 1 (1.5%) Eye color change 0 1 (1.5%) Eyeinflammation 0 1 (1.5%) Eye pruritus 0 1 (1.5%) General disorders and 01 (1.5%) administration site conditions Gait disturbance 0 1 (1.5%) ^(a)An adverse event that started in the double-blind induction phase andresulted in discontinuation in the follow-up phase is counted astreatment-emergent in the double-blind induction phase. Incidence isbased on the number of subjects experiencing at least one adverse event,not the number of events. Adverse events are coded using MedDRA version20.0.

TABLE 39 Treatment-emergent Adverse Events Leading to Discontinuation ofOral Antidepressant; Double-blind Induction Phase (Study ESKETINTRD3005:Safety Analysis Set) Intranasal Esk + Oral AD + Oral AD IntranasalPlacebo (N = 72) (N = 65) Total no. subjects with TEAE 1 (1.4%) 1 (1.5%)leading to discontinuation ^(a) Psychiatric disorders 1 (1.4%) 0 Anxietydisorder 1 (1.4%) 0 Eye disorders 0 1 (1.5%) Dry eye 0 1 (1.5%) Eyecolor change 0 1 (1.5%) Eye inflammation 0 1 (1.5%) Eye pruritus 0 1(1.5%) Skin and subcutaneous tissue 0 1 (1.5%) disorders Pruritus 0 1(1.5%) ^(a) An adverse event that started in the double-blind inductionphase and resulted in discontinuation in the follow-up phase is countedas treatment-emergent in the double-blind induction phase. Incidence isbased on the number of subjects experiencing at least one adverse event,not the number of events. Adverse events are coded using MedDRA version20.0.

Serious Adverse Events

Five subjects experienced serious treatment-emergent adverse eventsduring the double-blind phase. One subject in the esketamine+oral ADgroup experienced anxiety disorder which was considered as of possiblerelationship to both intranasal esketamine and oral AD. One subject inthe esketamine+oral AD group experienced blood pressure increased whichwas considered as of probable relationship to intranasal esketamine andnot related to oral AD. In addition, one subject in the esketamine+oralAD group experienced hip fracture which was considered not related toboth intranasal esketamine and oral AD. One subject in the oralAD+placebo group experienced feelings of despair and gait disturbance.The first event was considered as of possible relationship to intranasalplacebo and not related to oral AD. The second event was considered asof possible relationship to intranasal placebo and very likelyrelationship to oral AD. One subject in the oral AD+placebo groupexperienced dizziness which was considered as of doubtful relationshipto both intranasal placebo and oral AD.

Blood Pressure

Transient blood pressure increases peaked for the esketamine+oral ADgroup peaked at approximately 40 minutes post dose and returned tonormal range at 90 minutes. The maximum mean increases (across alldosing days) in systolic BP was 16.0 mm Hg in the esketamine+oral ADgroup and 11.1 mm Hg in the oral AD+placebo group. The maximum meanincreases (across all dosing days) in diastolic BP were 9.5 mm Hg in theesketamine+oral AD group and 6.8 mm Hg in the oral AD+placebo group.FIGS. 20 and 21 present means for blood pressure over time by treatmentgroup in the double-blind phase.

Clinician-Assessed Dissociative Symptom Scale (CADSS)

The Clinician Administered Dissociative States Scale (CADSS) wasmeasured prior to the start of each dose, at 40 minutes, and 1.5 hourspostdose. The CADSS is used to assess treatment emergent dissociativesymptoms and perceptual changes and the total score ranges from 0 to 92with a higher score representing a more severe condition.

The dissociative and perceptual change symptoms measured by the CADSS,suggest these symptoms had an onset shortly after the start of the doseand resolved by 1.5 hours postdose. See, FIG. 22. The proportion ofsubjects with sedation (post dose MOAA/S score of ≤3) was <4% for theesketamine group for each dosing day.

Modified Observer's Assessment of Alertness/Sedation (MOAA/S)

The Modified Observer's Assessment of Alertness/Sedation (MOAA/S) wasused to measure treatment-emergent sedation with correlation to levelsof sedation defined by the American Society of Anesthesiologists (ASA)continuum. The MOAA/S scores range from 0 (No response to painfulstimulus; corresponds to ASA continuum for general anesthesia) to 5(Readily responds to name spoken in normal tone [awake]; corresponds toASA continuum for minimal sedation). The proportion of subjectsexperienced MOAN/S scores ≤3 post dose by dose day is presented in Table40. The proportion of subjects with sedation was <4% for the esketaminegroup for each dosing day.

TABLE 40 Modified Observer's Assessment of Alertness/Sedation (MOAA/S):Frequency of Subjects with a Score of 3 or Less by Dose Day;Double-blind Induction Phase (Study ESKETINTRD3005: Safety Analysis Set)Intranasal Esk + Oral AD + Oral AD Intranasal Placebo (N = 72) (N = 65)Score ≤3 on Day 1, n (%) 70 64 Yes  0  0 No  70 (100.0%) 64 (100.0%)Score ≤3 on Day 4, n (%) 67 65 Yes 2 (3.0%) 1 (1.5%)  No 65 (97.0%) 64(98.5%)  Score ≤3 on Day 8, n (%) 63 62 Yes 2 (3.2%)  0 No 61 (96.8%) 62(100.0%) Score ≤3 on Day 11, n (%) 65 60 Yes 2 (3.1%)  0 No 63 (96.9%)60 (100.0%) Score ≤3 on Day 15, n (%) 60 59 Yes 1 (1.7%)  0 No 59(98.3%) 59 (100.0%) Score ≤3 on Day 18, n (%) 58 60 Yes 2 (3.4%)  0 No56 (96.6%) 60 (100.0%) Score ≤3 on Day 22, n (%) 60 56 Yes 1 (1.7%)  0No 59 (98.3%) 56 (100.0%) Score ≤3 on Day 25, n (%) 63 54 Yes  0  0 No 63 (100.0%) 54 (100.0%) MOAA/S score ranges from 0 (no response topainful stimulus) to 5 (readily responds to name spoken in normal tone[awake]).

Pharmacokinetics

Venous blood samples of approximately 2 mL were collected formeasurement of plasma concentrations of esketamine, noresketamine, andother metabolites (if warranted) at the time points specified in theTime and Events Schedule as described in Example 1. Plasma samples wereanalyzed as described in Example 1.

Pharmacokinetic Parameters: The plasma concentration-time data ofesketamine (and noresketamine, if warranted) was analyzed as describedin Example 1.Pharmacokinetic/Pharmacodynamic Evaluations: The relationship betweenMADRS total score (and possibly selected adverse events as additional PDparameters) and PK metrics of esketamine were evaluated as described inExample 1.

Biomarker, Pharmacogenomic (DNA), and Expression (RNA) Evaluations

During the study, blood was collected for the assessment of biomarkersat the time points indicated in the Time and Events schedule asdescribed in Example 1.

In blood, biomarkers (protein, metabolite, and ribonucleic acid [RNA])related to (but not limited to) the immune system activity, hypothalamuspituitary adrenal (HPA) axis activation, neurotrophic factors, andmetabolic factors were investigated as described in Example 1.

Blood samples for DNA analyses were collected at the time pointsindicated in the Time and Events Schedule for the assessment of geneticand epigenetic variation in genes in pathways relevant to depression(e.g., HPA axis, inflammation, growth factors, monoamine transporters,ion channels, and circadian rhythm) as described in Example 1.

Medical Resource Utilization: Medical resource utilization data,associated with medical encounters, were collected during the follow-upphase of the study as described in Example 1.Pharmacokinetic Analyses: Pharmacokinetic analyses were performed asdescribed in Example 1.Pharmacokinetic/Pharmacodynamic Analyses: The relationship between MADRStotal score (and possibly selected adverse events as additional PDparameters) and PK metrics of esketamine were evaluated as described inExample 1.Biomarker and Pharmacogenomic Analyses: Biomarker and pharmacogenomicsanalyses were performed as described in Example 1.

Statistical Methods Used in Analysis

A general description of the statistical methods used to analyze theefficacy and safety data is outlined in Example 1.

Interim Analysis for Sample Size Re-estimation or Stopping for Futility:An interim analysis for sample size re-estimation or stopping forfutility was performed as described in Example 1.Efficacy Analyses: Efficacy analyses were performed as described inExample 1.

Analysis of the US Subpopulation—Clinical Efficacy and Safety

Although the primary efficacy analysis using the weighted combinationtest was not statistically significant, treatment differences wereclinically meaningful for ESK+AD change compared to AD+PBO for improvingdepressive symptoms, as assessed by change in MADRS total score after 28days in elderly subjects with TRD. Based on MMRM analysis, themedian-unbiased estimate of the difference between ESK+AD and AD+PBO was−3.6 (95% CI: −7.20, 0.07). The differences were similar to those seenin studies that assessed SSRI/SNRI oral ADs against placebo in adultswith depression.

The greater numerical improvement in depression response (approximately2 times greater) and remission rates (approximately 3 times greater) forESK+AD compared to AD+PBO at Day 28 suggested a true clinical benefit oftreatment with esketamine nasal spray plus an oral antidepressant inelderly subjects with TRD.

There was also a clinically meaningful treatment difference forimprovement in the overall severity of depressive illness based on CGI-Sscore for ESK+AD over AD+PBO.

A. Outcomes

For the clinician-rated assessments, MADRS was administered at baselineand days 8, 15, 22 and 28. MADRS scores were obtained remotely bytelephone by independent raters blinded to subject's treatment response.Similarly, the Clinical Global Impressions-Severity (CGI-S) scale wasadministered at baseline: days 4, 8, 11, 15, 18, 22, 25; and at the4-week double-blind end point.

For the patient-rated assessments, a 9-item Patient AdherenceQuestionnaire-9 (PHQ-9) and Sheehan Disability Scale (SDS) wereadministered at baseline, day 15, and day 28. Although PHQ-9 and SDSassessments were eliminated by study amendment, site pads were notmodified, therefore data were collected.

B. Patient Demographics/Disease Characteristics

Inclusion criteria included adults, aged ≥65 years, who met DSM-5diagnostic criteria for recurrent MDD without psychotic features orsingle episode MDD (with duration of episode >2 years) and Inventory ofDepressive Symptoms-Clinician rated, 30-item score of ≥31.

Inclusion criteria also included nonresponsive (≤25% improvement in theMADRS) to ≥1 but ≤8 AD treatments in the current episode of depressiontaken for at least 6 weeks at a therapeutic dose (based on theMassachusetts General Hospital Antidepressant Treatment ResponseQuestionnaire-geriatric version).

Patients must have had a current major depressive episode, depressionsymptom severity (Week 1 MADRS total score ≥24), and AD treatmentresponse in the current depressive episode, confirmed using a SiteIndependent Qualification Assessment

Of the 70 US patients aged ≥65 years, 34 received ESK+AD and 36 receivedAD+PBO. The baseline patient demographics and disease characteristicswere generally similar between the 2 treatment groups (Table 41). Theoverall mean age was 70.0 years, 57.1% were women, and most patientswere white (98.6%). The mean age at MDD diagnosis was 42.5 years,indicating on average, a >27-year history of depression in thispopulation. The baseline MADRS, CGI-S and PHQ-9 scores were consistentwith an adult population with TRD.

TABLE 41 Baseline patient demographics and disease characteristics in USpatients ESK + AD AD + PBO Parameter (n = 34) (n = 36) Age, y, mean (SD)70.7 (4.5) 69.3 (4.1) Sex, n (%) Male 15 (44.1) 15 (41.7) Female 19(55.9) 21 (58.3) Race, n (%) White 33 (97.1) 36 (100.0) Multiple 1 (2.9)0 Class of oral ADs, n (%)† SNRI 16 (47.1) 17 (47.2) SSRI 18 (52.9) 19(52.8) Duration of current episode, weeks, 187.6 (283.4) 420.9 (480.7)mean (SD) Age at MDD diagnosis, yr, mean (SD) 42.1 (15.3) 43.0 (15.1)MADRS total score,^(a) mean (SD) 35.5 (5.5) 35.7 (6.0) CGI-S,^(b) mean(SD) 5.0 (0.6) 4.7 (0.6) PHQ-9 total score,^(c) mean (SD) 15.2 (5.6)18.2 (5.6) SDS total score,^(d) mean (SD) 20.9 (6.19) 22.1 (4.72)

C. Efficacy

Efficacy was determined by measuring MADRS total scores, SDS scores,PHQ-9 scores, and CGI-S scores. The primary efficacy endpoint, comparedbetween treatment groups, was the change in the MADRS total score frombaseline to day 28. Other efficacy measures were changes in CGI-Sscores, SDS total scores, and PHQ-9 total scores, which assessed changesin general clinical condition and function. Efficacy analysis wasconducted at a one-sided 0.025 level of significance.

For the MADRS, PHQ-9, and SDS total scores, the test for treatmenteffect was based on mixed model for repeated measures (MMRM) on observedcase data with change from baseline as the response variable and thefixed effect model terms for treatment (ESK+AD, AD+PBO), day, class oforal AD (SNRI or SSRI), and treatment-by-day, and baseline value as acovariate. For the CGI-S scores, the test for treatment effect was basedon analysis of covariance (ANCOVA) model on last observation carriedforward (LOCF) data on ranks of change from baseline as the responsevariable and factors for treatment (ESK+AD, AD+PBO), and class of oralAD (SNRI or SSRI), and baseline value (unranked) as a covariate.

The results illustrate that the least square (LS) mean changes in MADRStotal score decreased in both treatment groups during the 4-weekdouble-blind induction phase. See, FIG. 29. Statistically significantimprovement in MADRS total score was observed with ESK+AD vs AD+PBO atday 28 (LS mean difference [SE]: −5.4 [2.48]; 1-sided P=0.016). See,Table 42.

In summary, ESK+AD compared with AD+PBO (active comparator) demonstrateda clinically meaningful, statistically significant reduction ofdepressive symptoms and an improvement in overall severity of depressiveillness and in health-related quality of life and functioning in USpatients aged ≥65 years with TRD at 4 weeks.

TABLE 42 Change from baseline in MADRS total score (observed case) in USpatients aged ≥65 years with TRD ESK + AD AD + PBO MADRS parameter (n =34) (n = 36) Total score at baseline, mean (SD) 35.5 (5.5) 35.7 (6.0) Change at day 8 N 32 35 LS mean change −6.3 −4.7 LS mean difference fromAD + PBO (SE) −1.6 (1.71) P value .176 Change at day 28 (4-weekspost-initial dose) N 30 34 LS mean change −11.9 −6.5 LS mean differencefrom AD + PBO (SE) −5.4 (2.48) P value .016 MADRS total score rangesfrom 0 to 60; a higher score indicated a more severe condition.

Clinician-rated severity of depressive illness as assessed by CGI-S wassimilar 4 days post-initial dose. However, a statistically significantdifference in improvement of severity of depressive illness as measuredby CGI-S was observed between the two treatment groups 4 weekspost-initial dose (1-sided P=0.005). See, Table 43.

TABLE 43 Change from baseline in PHQ-9 and SDS total scores (observedcase) in US patients aged ≥65 years with TRD ESK + AD AD + PBO Parameter(n = 34) (n = 36) PHQ-9 total score Baseline, mean (SD) 15.2 (5.6)  18.2(5.6)  Change at day 15 N 25 23 LS mean change −6.1 −3.0 LS meandifference from AD + −3.1 (1.38) PBO (SE) P value 0.015 Change at day 28N 31 32 LS mean change −7.4 −3.0 LS mean difference from AD + −4.4(1.68) PBO (SE) P value 0.006 SDS total score Baseline, mean 20.9 (6.19)22.1 (4.72) Change at day 15 N 9 12 LS mean change −5.5 −9.0 LS meandifference from AD +  3.5 (4.15) PBO (SE) P value 0.794 Change at day 28N 11 19 LS mean change −10.8 −3.2 LS mean difference from AD + −7.6(2.68) PBO (SE) P value 0.004 PHQ-9 total score ranges from 0 to 27; ahigher score indicates greater depression. SDS total scores range from 0to 30, where 0 = unimpaired and 30 = highly impaired.

The frequency distribution of illness severity based on CGI-S scores atbaseline and the double-blind phase endpoint are shown in FIG. 30. Atbaseline, the percentage of patients with normal/borderline/mild illnesswas similar in the ESK+AD and AD+PBO groups (2.9% and 2.8%,respectively). At the double-blind endpoint, the percentage of patientswith normal/borderline/mild illness was 3.8-fold higher in the ESK+ADgroup compared with the AD+PBO group (42.4% and 11.2%, respectively).

The patient-rated severity of depressive illness, as assessed by PHQ-9total scores, and functional impairment, as assessed by SDS totalscores, decreased in both treatment groups, but the magnitude ofdifference was significantly greater in the ESK+AD group at day 28. See,Table 24. For PHQ-9, the LS mean difference (SE) was −4.4 (1.68; 1-sidedP=0.006). For SDS, the LS mean difference (SE) was −7.6 [2.68; 1-sidedP=0.004].

D. Safety

Safety evaluation included reported adverse events, clinical laboratorytests, vital sign measurements, physical examinations,electrocardiograms and nasal examinations. Safety was assessed viatreatment emergent AEs (TEAEs). Overall, TEAEs were observed in 64.7% ofUS patients in the ESK+AD group and 58.3% of patients in the AD+PBOgroup. See, Table 25. There were no deaths. One serious AE was observedin each group. Three patients withdrew the nasal spray (n=2 ESK[systolic BP increase >180; hip fracture], n=1 PBO) and one patient inthe AD+PBO group withdrew oral AD (elevated BP, dizziness, andperipheral edema). Most TEAEs were mild or moderate in severity, and nonew or unexpected safety signals were observed.

The most common (25% in either treatment group) TEAEs are shown in Table44. TEAEs tended to be mild to moderate in severity and transient innature. The incidence of AEs in the US patients was similar to thatobserved in the overall study population. Results show that ESK+ADshowed statistically significant, clinically meaningful AD efficacy inpatients aged ≥65 years with a safety profile similar to that observedin younger patients. These observations are similar to the globalanalysis, which shows clinically meaningful AD efficacy and were similarto those found for the younger population in the ESK phase 3 study andin the phase 2 studies.

TABLE 44 Overview of treatment-emergent adverse events in US patientsaged ≥65 years ESK + AD PBO + AD Parameter (n = 34) (n = 36) OverallTEAE, n (%) 22 (64.7) 21 (58.3) Possibly related to nasal spray 15(44.1) 10 (27.8) Possibly related to oral AD 7 (20.6) 7 (19.4) Leadingto death 0 0 1 or more serious TEAE 1 (2.9) 1 (2.8) Leading to nasalspray withdrawal 2 (5.9) 1 (2.8) Leading to oral AD withdrawal 0 1 (2.8)Most common (≥5% in either treatment group) TEAEs Dysphoria 4 (11.8) 0Fatigue 4 (11.8) 3 (8.3) Headache 4 (11.8) 1 (2.8) Insomnia 4 (11.8) 2(5.6) Nausea 4 (11.8) 0 Abdominal discomfort 2 (5.9) 1 (2.8) Cough 2(5.9) 0 Dizziness 2 (5.9) 2 (5.6) Erythema 2 (5.9) 1 (2.8) Nasalcongestion 2 (5.9) 0 Urinary tract infection 2 (5.9) 0 Vomiting 2 (5.9)0 Anxiety 1 (2.9) 2 (5.6) Viral upper respiratory tract infection 1(2.9) 2 (5.6) Muscle strain 0 2 (5.6)

Analysis of the US Subpopulation—Response, Remission, and Safety

As discussed above for the overall analysis, ESK+AD demonstratedstatistically significant and clinically meaningful superiority comparedwith AD+PBO in primary efficacy endpoint (i.e., change from baseline inthe MADRS total score in geriatric patients. See, Montgomery citedabove. In this analysis, the response, remission, and safety of thesetreatment groups were analyzed in only US geriatric patients and toassess for differences in efficacy and safety between the US populationand the overall study population.

A. Outcomes

For the clinician-rated assessments, MADRS was administered at baselineand days 8, 15, 22, and 28. Similarly, the Clinical GlobalImpressions-Severity (CGI-S) scale was administered at baseline and days4, 8, 11, 15, 18, 22, 25 and 28.

For the patient-rated assessment, a 9-item Patient AdherenceQuestionnaire-9 (PHQ-9) was administered at baseline, day 15, and day28.

B. Patient Demographics/Disease Characteristics

Inclusion criteria included adults, aged ≥65 years, who met Diagnosticand Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)diagnostic criteria for recurrent MDD without psychotic features orsingle episode MDD (with duration of episode >2 years). Nonresponsive(≤25% improvement in the Montgomery-Asberg Depression Rating Scale[MADRS]) to ≥1 but ≤8 AD treatments in the current episode of depressiontaken for at least 6 weeks at a therapeutic dose (based on theMassachusetts General Hospital Antidepressant Treatment ResponseQuestionnaire—geriatric version). Inventory of DepressiveSymptoms-Clinician rated, 30-item score of 231. Current major depressiveepisode, depression symptom severity (Week 1 MADRS total score ≥24), andAD treatment response in the current depressive episode, confirmed usinga Site Independent Qualification Assessment.

Of 70 US patients aged ≥65 years, 34 received ESK+AD and 36 receivedAD+PBO. The baseline patient demographics and disease characteristicswere generally similar between the 2 treatment groups. See, Table 45.Overall mean age was 70.0 years, 57.1% were women, and most patientswere white (98.6%). The mean age at MDD diagnosis was 42.5 years,indicating on average, a >27-year history of depression in thispopulation. The baseline MADRS, CGI-S and PHQ-9 scores were consistentwith an adult population with TRD.

TABLE 45 Baseline patient demographics and disease characteristics ESK +AD AD + PBO Parameter (n = 34) (n = 36) Age, y, mean (SD) 70.7 (4.5)69.3 (4.1) Sex, n (%) Male 15 (44.1) 15 (41.7) Female 19 (55.9) 21(58.3) Race, n (%) White 33 (97.1) 36 (100.0) Multiple 1 (2.9) 0 Classof oral ADs, n (%)† SNRI 16 (47.1) 17 (47.2) SSRI 18 (52.9) 19 (52.8)Duration of current episode, weeks, 187.6 (283.4) 420.9 (480.7) mean(SD) Age at MDD diagnosis, y, mean (SD) 42.1 (15.3) 43.0 (15.1) MADRStotal score,^(a) mean (SD) 35.5 (5.5) 35.7 (6.0) CGI-S,^(b) mean (SD)5.0 (0.6) 4.7 (0.6) PHQ-9 total score,^(c) mean (SD) 15.2 (5.6) 18.2(5.6) ^(a)MADRS total score ranged from 0 to 60; a higher scoreindicates a more severe condition. ^(b)CGI-S score ranges from 1(normal, not at all ill) to 7 (among the most extremely ill patients).^(c)PHQ-9 total score ranges from 0 to 27; a higher score indicatesgreater depression.

C. Efficacy

Efficacy was determined by measuring MADRS total scores, SDS scores,PHQ-9 scores and CGI-S scores. A patient was considered responsive ifthere was a ≥50% decrease in MADRS baseline score. A patient wasclassified to be “in remission” if the clinician-rated: MADRS score was≤12 and the patient-rated PHQ-9 score was <5. A patient was consideredto have a change in clinician-rate symptom severity if there was aclinically meaningful response with a ≥1-point decrease in the CGI-S anda clinically significant response with a ≥2-point decrease on the CGI-S.

Approximately, eight days post initial dose, response rates based onMADRS were 6.3% (2/32) and 0% (0/35) in ESK+AD and AD+PBO, respectively.

Twenty-eight days post-initial dose, response rates based on MADRS werenearly 2-fold higher in patients treated with ESK+AD compared withpatients treated with AD+PBO (8/30 [26.7%] vs 5/34 [14.7%]). See, FIG.31. Twenty-eight days post-initial dose, remission rates based on MADRSwere approximately 5-fold greater in patients treated with ESK+ADcompared with patients treated with AD+PBO (5/30 [16.7%] vs 1/34[2.9%]). See, FIG. 32. At day 28 post-initial dose, patient-ratedremission was almost 2.5-fold higher in the ESK+AD group compared withAD+PBO group (22.6% [7/31] vs 9.4% [3/32]). See, FIG. 33.

At day 15 post-initial dose, patient-rated remission rates based onPHQ-9 were similar between treatment groups (8.0% [2/25] vs 8.7%[2/23]).

At 4 weeks post-initial dose, clinically meaningful response was nearly2-fold higher, and clinically significant response was nearly 4-foldhigher, in the ESK+AD group compared with the AD+PBO group (63.3% vs29.4% and 43.2% vs 11.8%, respectively). See, FIGS. 34 and 35.

D. Safety

Safety was assessed via treatment emergent AEs (TEAEs). Overall, TEAEswere observed in 64.7% of US patients in the ESK+AD group and 58.3% ofpatients in the AD+PBO group. See, Table 27. There were no deaths; oneserious AE was observed in each group. Three patients withdrew nasalspray (n=2 ESK [systolic BP increase >180; hip fracture], n=1 PBO) andone patient in the AD+PBO group withdrew oral AD (elevated BP,dizziness, and peripheral edema).

The most common (≥5% in either treatment group) TEAEs are shown in Table46. TEAEs tended to be mild to moderate in severity and transient innature. The incidence of TEAEs in the US patients was similar to thatobserved in the overall study population.

TABLE 46 Overview of treatment-emergent adverse events in US patientsaged ≥65 years ESK + AD AD + PBO Parameter (n = 34) (n = 36) OverallTEAE, n (%) 22 (64.7) 21 (58.3) Possibly related to nasal spray 15(44.1) 10 (27.8) Possibly related to oral AD 7 (20.6) 7 (19.4) Leadingto death 0 0 1 or more serious TEAE 1 (2.9) 1 (2.8) Leading to nasalspray withdrawal 2 (5.9) 1 (2.8) Leading to oral AD withdrawal 0 1 (2.8)Most common (≥5% in either treatment group) TEAEs Dysphoria 4 (11.8) 0Fatigue 4 (11.8) 3 (8.3) Headache 4 (11.8) 1 (2.8) Insomnia 4 (11.8) 2(5.6) Nausea 4 (11.8) 0 Abdominal discomfort 2 (5.9) 1 (2.8) Cough 2(5.9) 0 Dizziness 2 (5.9) 2 (5.6) Erythema 2 (5.9) 1 (2.8) Nasalcongestion 2 (5.9) 0 Urinary tract infection 2 (5.9) 0 Vomiting 2 (5.9)0 Anxiety 1 (2.9) 2 (5.6) Viral upper respiratory tract infection 1(2.9) 2 (5.6) Muscle strain 0 2 (5.5)

E. Conclusions

These results demonstrated that, in this subpopulation of US patientsaged ≥65 years with TRD from a larger, multinational study, almost twiceas many patients attained response (i.e., ≥50% decrease in MADRSbaseline score) when treated with ESK+AD compared with those treatedwith AD+PBO. In addition, remission rates (i.e., MADRS score ≤12) wereapproximately 5-fold greater in patients treated with ESK+AD comparedwith patients treated with AD+PBO.

Thus, ESK+AD demonstrated clinically meaningful and clinicallysignificant improvement in clinician-rated (CGI-S) and patient-rated(PHQ-9) remission. The safety, response, and remission results of USpatients were similar to those found for the total population studied.

Example 3

This was a randomized, double-blind, placebo-controlled, multicenterstudy. See, Camusso, “Efficacy and Safety of Intranasal Esketamine forthe Rapid Reduction of Symptoms of Depression and Suicidality inPatients at Imminent Risk for Suicide: Results of a Double-Blind,Randomized Placebo-Controlled Study,” Am. J. Psych., 2018, 1-11, whichis herein incorporated by reference. Approximately 70 male and femalesubjects, 19 to 64 years of age, with MDD at imminent risk for suicidepresenting to an emergency room (ER) or other permitted setting andassessed to be at imminent risk for suicide were enrolled. The majorityof subjects were female, and the mean age of all subjects wasapproximately 36 years. The mean baseline Montgomery-Asberg DepressionRating Scale (MADRS) total score was over 38 (corresponding to severedepression), and the mean baseline Beck Scale for Suicidal Ideation(BSS) score was over 22. Over half of the subjects had a score of 6 onthe Suicide Ideation and Behavior Assessment Tool (SIBAT) ClinicalGlobal Judgment of Suicide Risk, corresponding to suicidal riskrequiring hospitalization with suicide precautions. A diagram of thestudy design is provided in FIG. 37.

The study consisted of a screening evaluation performed within 24 hours(or up to 48 hours upon consultation with the Sponsor's medical monitor)prior to Day 1 dose, immediately followed by a 25-day double-blindtreatment phase (Day 1 to 25) with twice a week dosing, and a 56-dayfollow up phase (Day 26 to Day 81). The study was designed as a POCstudy and therefore a two-sided 0.20 significance level was used.

Randomization: 68 subjects were randomized in a 1:1 ratio to 1 of the 2treatments: intranasal esketamine 84 mg (N=36) or intranasal placebo(N=32). The randomization was stratified by study center and by thephysician's assessment of the subject's need of standard of careantidepressant treatment prior to randomization on Day 1 (i.e.,antidepressant monotherapy or antidepressant plus augmentation therapy).In addition, all subjects received aggressive clinical care, includinghospitalization and the initiation or optimization of standardantidepressant medication (determined by the treating physician based onclinical judgment and practice guidelines).

Primary analysis set for efficacy: The primary efficacy analyses wasbased on the intent-to-treat (ITT) analysis set which was defined toinclude all randomized subjects who receive at least 1 dose of studymedication during the double-blind phase and have both baseline and theDay 1, 4-hour postdose evaluation for the MADRS total score.

Primary efficacy variable/Primary Time point: Change from baseline (Day1, predose) to Day 1, 4-hours postdose in MADRS total score. The MADRSconsists of 10 items that cover all of the core depressive symptoms,with each item scoring from 0 (item is not present or is normal) to 6(severe or continuous presence of the symptom). A higher scorerepresents a more severe condition.

Secondary efficacy variables:

-   -   a. Changes from baseline to Day 2 and Day 25 for the MADRS total        score    -   b. Changes from baseline to Day 1 4-hours postdose, Day 2 and        Day 25 for the MADRS Suicide Item    -   c. Changes from baseline to Day 1 4-hours postdose, Day 2, and        Day 25 for the clinical global judgment of suicide risk from the        Suicide Ideation and Behavior Assessment Tool (SIBAT)    -   d. Sustained response (Onset of Clinical Response) defined as at        least 50% reduction from baseline in MADRS total score with        onset on Day 1 that is maintained through the end of the        double-blind phase (Day 25)    -   e. Changes from baseline to Day 1 4-hours postdose, Day 2, and        Day 25 for the Beck Scale for Suicidal Ideation (BSS)    -   f. Changes from baseline to Day 1 4-hours postdose and Day 25        for the Beck Hopelessness Scale

Expected effect size and planned sample size: The sample size was basedon the assumption of a treatment difference of at least 6 points in themean change from baseline to Day 1 (4 hours postdose) in MADRS totalscore between the esketamine and placebo groups. A standard deviation of9 was used for both groups. Using a 2-sample t-test, 32 subjects in eachgroup were required to detect the treatment difference of 6 points witha power of 91% at an overall 1-sided significance level of 0.10 (whichis the same as a 2-sided significance level 0.20). Assuming 8% ofrandomized subjects discontinue before providing post-baseline efficacymeasurements, the total number of subjects required for each treatmentgroup is 35. The goal of sample size selection for this Phase 2aproof-of-concept study was to increase sensitivity for detecting atherapeutic signal while also maintaining a modest sample size. Thus,power was set to a high value (≥90%; β≤0.1) but the type 1 error ratewas specified at 1-sided α=0.10.

Primary Objective: The primary objective is to evaluate the efficacy ofintranasal esketamine 84 mg compared with intranasal placebo in reducingthe symptoms of MDD, including suicidal ideation, in subjects who areassessed to be at imminent risk for suicide, as measured by the changefrom baseline on the Montgomery-Asberg Depression Rating Scale (MADRS)total score at 4 hours postdose on Day 1.

Subject and Treatment Information:

This was a randomized, double-blind, placebo-controlled study thatincluded 68 randomized subjects with a diagnosis of MDD at imminent riskfor suicide without psychotic features, based upon clinical assessment(DSM-IV 296.22, 296.23, 296.32, or 296.33) and confirmed by the MiniInternational Psychiatric Interview (MINI). Subjects must have hadcurrent suicidal ideation with intent, confirmed by a “Yes” response toQuestion B5 [Think about suicide (killing yourself)?] and Question B9[Intend to act on thoughts of killing yourself?] obtained from the MINI;and subjects must have had a MADRS total score of 222 predose on Day 1.Due to the lower than assumed dropout rate at the time of the primaryendpoint (Day 1: 4 hours postdose), study recruitment was discontinuedat 68 subjects which is a sufficient number of evaluable subjects. Ofthe 68 randomized subjects, 2 subjects did not receive study drug andare therefore not included in the safety or ITT analysis sets. In theITT analysis set, 35/66 (53.0%) of the subjects were white and 43/66(65.2%) of the subjects were female. The mean age was 35.8 years,ranging from 19 to 64 years. Out of 68 subjects in the all randomizedanalysis set, 49 (72.1%) completed the double-blind phase and 19withdrew early, of which 6 withdrew due to adverse events, 5 due to lackof efficacy, 2 for loss to follow-up, 2 due to withdrawal of consent and4 due to other reasons. Subsequently, 49 subjects entered into the56-day follow-up phase.

Efficacy: Primary Efficacy Endpoint

Based on an ANCOVA model, results for the change from baseline to Day 1,4-hours postdose in MADRS total score favored esketamine 84 mg with aleast-square mean difference (SE) from placebo of −5.3 (2.10). Thedifference between treatment groups was statistically significant(two-sided p=0.015), using a two-sided significance level of 0.20.

Secondary Efficacy Endpoints

Table 47 below summarizes the results of the secondary efficacyendpoints.

TABLE 47 Assessment Time Two-sided p-value MADRS Day 2 (DB) 0.015 EndPoint (DB) 0.159 MADRS Suicide Item Day 1: 4-hours postdose 0.002 Day 2(DB) 0.129 End Point (DB) 0.143 SIBAT Clinical Global Day 1: 4-hourspostdose 0.112 Judgment of Suicide Risk Day 2 (DB) 0.150 End Point (DB)0.922 Sustained Response Day 1 until the end of 0.608 (Onset of ClinicalDB phase Response) BSS Day 1: 4-hours postdose 0.326 Day 2 (DB) 0.415End Point (DB) 0.431 BHS Day 1: 4-hours postdose 0.297 End Point (DB)0.165 Statistical significance for this proof-of-concept study was basedon a two-sided 0.20 significance level.

Safety

The most common (≥20%) TEAEs in the esketamine 84 mg group during thedouble-blind phase were nausea (37.1%), dizziness (34.3%), dysgeusia(31.4%), headache (31.4%), dissociation (31.4%) and vomiting (20.0%).The most common (≥20%) TEAE in the placebo group was headache (25.8%).

Four subjects experienced a serious treatment-emergent adverse eventduring the double-blind phase and all were in the esketamine 84 mggroup. Two subjects experienced suicidal ideation, 1 subject experiencedagitation, and 1 subject experienced depressive symptoms. Six subjectsexperienced a serious adverse event during the follow up phase (5 in theplacebo group and 1 in the esketamine 84 mg group). The SAEs in theplacebo group included 3 suicide attempts (non-fatal), 1 subject whoexperienced suicidal ideation, and 1 subject with cellulitis. The SAE inthe subject from the esketamine group was suicidal ideation.

There were 6 subjects (1 subject in the placebo group and 5 subjects inthe esketamine 84 mg group), who discontinued from the double-blindphase due to treatment-emergent adverse events.

Transient blood pressure increases for the esketamine 84 mg group peakedat 40 minutes post dose with the maximum mean increases (across alldosing days) in systolic BP being 8.7 and 16.7 in the placebo andesketamine 84 mg groups, respectively. The maximum mean increases(across all dosing days) in diastolic BP were 7.6 and 11.9 in theplacebo and esketamine 84 mg groups, respectively.

The dissociative and perceptual change symptoms measured by the CADSS,suggest onset of these symptoms occurred shortly after the start of thedose and resolved by 2 hours post dose.

RESULTS Subject and Treatment Information

In total, 68 subjects with a DSM-IV-TR (Diagnostic and StatisticalManual, 4th Edition—Text Revised) diagnosis of MDD (aged 19-64 years)were randomized to two groups in a ratio of 1:1 (32 in placebo and 36 inesketamine 84 mg). The number of subjects included in each analysis setis included in Table 48. All subjects enrolled were from the US.

Among 68 randomized subjects, 66 were included in the safety analysisset (defined as receiving at least one dose of study medication in thedouble-blind phase). Two subjects were randomized but did not receivestudy medication. All safety subjects (N=66) were included in theintent-to-treat (ITT) analysis set (defined as receiving at least onedose of study medication during the double-blind phase and having boththe baseline and the Day 1, 4-hour postdose evaluation for the MADRStotal score). Forty-nine subjects were included in the safety (FU)analysis set (defined as all subjects who have at least 1 visit duringthe follow up phase).

TABLE 48 Number of Subjects in Each Analysis Set (Study ESKETINSUI2001:All Randomized Analysis Set) Placebo Esketamine 84 mg Total (N = 32) (N= 36) (N = 68) All randomized  32 (100.0%)  36 (100.0%)  68 (100.0%) ITT31 (96.9%) 35 (97.2%) 66 (97.1%) Safety 31 (96.9%) 35 (97.2%) 66 (97.1%)ITT (FU) 22 (68.8%) 27 (75.0%) 49 (72.1%) Safety (FU) 22 (68.8%) 27(75.0%) 49 (72.1%) Percentages calculated with the number of subjects ineach group as denominator.

Study Completion/Withdrawal Information

Of the 68 subjects in the all randomized analysis set, 19 (27.9%)subjects discontinued from the double-blind phase. The completion andwithdrawal information for subjects in the double-blind phase isprovided in Table 49. More subjects in the esketamine 84 mg groupdiscontinued due to adverse events (5 subjects in the esketamine 84 mggroup versus 1 subject in the placebo group) whereas more subjects inthe placebo group discontinued due to lack of efficacy (4 subjects inthe placebo group versus 1 subject in the esketamine 84 mg group).

Four subjects withdrew due to other reasons during the double-blindphase. The details are provided below.

1) One subject (in the esketamine 84 mg group) experienced elevatedblood pressure after randomization but prior to dosing and was thuswithdrawn.

2) One subject (in the esketamine 84 mg group) withdrew due to lack oftransportation.

3) One subject (in the placebo group) changed her mind and decided notto participate in the trial. However, the study coordinator mistakenlyrandomized her into the trial.

4) One subject (in the placebo group) had no dose on Day 22 due to lackof clinician availability, then the subject did not show up for Day 25.The subject returned for the early withdrawal visit but did not returnfor the follow up phase.

TABLE 49 Study Completion/Withdrawal Information for Double-Blind Phase(Study ESKETINSUI2001: All Randomized Analysis Set) Placebo Esketamine84 mg Total (N = 32) (N = 36) (N = 68) Completed 22 (68.8%) 27 (75.0%)49 (72.1%) Withdrawn 10 (31.3%) 9 (25.0%) 19 (27.9%) Adverse event 1(3.1%) 5 (13.9%) 6 (8.8%) Lack of Efficacy 4 (12.5%) 1 (2.8%) 5 (7.4%)Lost to follow-up 2 (6.3%) 0 2 (2.9%) Withdrawal of consent 1 (3.1%) 1(2.8%) 2 (2.9%) Other 2 (6.3%) 2 (5.6%) 4 (5.9%)

Demographic and Baseline Characteristics

Demographic and baseline characteristics are displayed in Table 50 forthe ITT analysis set. In general, the treatment groups were similar withrespect to the baseline characteristics. The majority of subjectsentering the double-blind phase were female (65.2%). The mean (SD) ageof all subjects was 35.8 (13.03) years, ranging from 19 to 64 years.75.8% of subjects were to receive antidepressant monotherapy; 24.2% ofsubjects were to receive antidepressant plus augmentation therapy.

Baseline psychiatric history for the ITT analysis set is presented inTable 51. The mean (SD) baseline MADRS total score was 38.6 (6.53),ranging from 20 to 52. A majority of subjects had a score of 6 on theclinical global judgment of suicide risk as assessed by the SIBAT Module8 (51.5%). Values of 6 correspond to suicidal risk requiringhospitalization with suicide precautions.

TABLE 50 Demographic and Baseline Characteristics (Study ESKETINSUI2001:ITT Analysis Set) Placebo Esketamine 84 mg Total (N = 31) (N = 35) (N =66) Age (years) N 31 35 66 Mean (SD) 36.0 (12.82) 35.7 (13.40) 35.8(13.03) Median   31.0   32.0   31.5 Range (19; 64) (19; 64) (19; 64) AgeCategory, n (%) 18-34 18 (58.1%) 18 (51.4%) 36 (54.5%) 35-54 10 (32.3%)12 (34.3%) 22 (33.3%) 55-64 3 (9.7%) 5 (14.3%) 8 (12.1%) Sex, n (%) N 3135 66 Male 10 (32.3%) 13 (37.1%) 23 (34.8%) Female 21 (67.7%) 22 (62.9%)43 (65.2%) Race, n (%) N 31 35 66 White 15 (48.4%) 20 (57.1%) 35 (53.0%)Black or African American 13 (41.9%) 12 (34.3%) 25 (37.9%) Asian  0 1(2.9%) 1 (1.5%) Multiple 1 (3.2%)  0 1 (1.5%) Other 2 (6.5%)  0 2 (3.0%)Not Reported  0 2 (5.7%) 2 (3.0%) Ethnicity, n (%) N 31 35 66 NotHispanic or Latino 29 (93.5%) 31 (88.6%) 60 (90.9%) Hispanic or Latino 1(3.2%) 4 (11.4%) 5 (7.6%) Not Reported 1 (3.2%)  0 1 (1.5%) BaselineWeight (kg) N 31 35 66 Mean (SD) 76.1 (18.83) 83.5 (23.86) 80.0 (21.79)Median   75.0   77.1   75.4 Range  (48; 110)  (51; 149)  (48; 149)Baseline Height (cm) N 31 35 66 Mean (SD) 168.6 (7.15) 167.9 (15.64)168.2 (12.31) Median  167.1  167.6  167.6 Range (156; 182) (108; 203)(108; 203) Baseline Body Mass Index (kg/m2) N 31 35 66 Mean (SD) 26.8(6.62) 30.1 (9.49) 28.5 (8.37) Median   25.0   28.6   26.6 Range (18;41) (17; 60) (17; 60) BMI Category (kg/m2), n (%) N 31 35 66 Underweight<18.5 2 (6.5%) 1 (2.9%) 3 (4.5%) Normal 18.5-<25 13 (41.9%) 12 (34.3%)25 (37.9%) Overweight 25-<30 6 (19.4%) 6 (17.1%) 12 (18.2%) Obese ≥30 10(32.3%) 16 (45.7%) 26 (39.4%) Standard of Care Antidepressant Treatmentas Randomized, n (%) N 31 35 66 Antidepressant monotherapy 25 (80.6%) 25(71.4%) 50 (75.8%) Antidepressant plus augmentation therapy 6 (19.4%) 10(28.6%) 16 (24.2%) Standard of Care Antidepressant Treatment as ActuallyReceived, n (%) N 31 35 66 Monotherapy 22 (71.0%) 24 (68.6%) 46 (69.7%)Augmentation 5 (16.1%) 9 (25.7%) 14 (21.2%) Both 4 (12.9%) 2 (5.7%) 6(9.1%)

TABLE 51 Baseline Psychiatric History by Treatment: (StudyESKETINSUI2001: ITT Analysis Set) Placebo Esketamine 84 mg Total (N =31) (N = 35) (N = 66) Baseline MADRS Total Score N 31 35 66 Mean (SD)38.8 (7.02) 38.5 (6.17) 38.6 (6.53) Median 40.0 38.0 38.5 Range (20;52)  (27; 49)  (20; 52)  Hx of Suicide Attempt Lifetime (%) 21 (67.7%)20 (57.1%) 41 (62.1%) Within last 30 Days (%) 13 (41.9%) 11 (31.4%) 24(36.4%) Baseline SIBAT (Module 2): Prior 4 Thought on Suicide, n (%) N31 34 65 Yes 31 (100.0%) 34 (100.0%) 65 (100.0%) No 0 0 0 Baseline SIBAT(Module 6): My Self- Assessment of Suicide Risk: Which rating bestdescribes your intent for suicide right now, n (%) N 31 35 66 None 3(9.7%) 3 (8.6%) 6 (9.1%) Very weak/Weak/Moderately weak 8 (25.8%) 7(20.0%) 15 (22.7%) Mild 6 (19.4%) 6 (17.1%) 12 (18.2%)Moderate/Moderately strong 9 (29.0%) 10 (28.6%) 19 (28.8%) Strong 3(9.7%) 5 (14.3%) 8 (12.1%) Extremely strong/Extremely strong 2 (6.5%) 4(11.4%) 6 (9.1%) and constant Baseline SIBAT (Module 8): Clinical GlobalJudgment of Suicide Risk, n (%) N 31 35 66 0 0 0 0 1 0 0 0 2 0 0 0 3 0 00 4 1 (3.2%) 0 1 (1.5%) 5 16 (51.6%) 15 (42.9%) 31 (47.0%) 6 14 (45.2%)20 (57.1%) 34 (51.5%) MINI B5: Think about suicide (killing yourself):Y/N, n (%) N 31 35 66 Yes 31 (100.0%) 35 (100.0%) 66 (100.0%) No 0 0 0MINI B5: Think about suicide (killing yourself): frequency, n (%) N 3135 66 Occasionally 5 (16.1%) 5 (14.3%) 10 (15.2%) Often 9 (29.0%) 11(31.4%) 20 (30.3%) Very Often 17 (54.8%) 19 (54.3%) 36 (54.5%) MINI B5:Think about suicide (killing yourself): Intensity, n (%) N 31 35 66 Mild1 (3.2%) 0 1 (1.5%) Moderate 9 (29.0%) 12 (34.3%) 21 (31.8%) Severe 21(67.7%) 23 (65.7%) 44 (66.7%) MINI B9: Intent to act on thoughts ofkilling yourself (Y/N), n (%) N 31 35 66 Yes 31 (100.0%) 35 (100.0%) 66(100.0%) No 0 0 0 Baseline BSS Total Score N 31 34 65 Mean (SD) 21.4(8.28) 24.0 (5.45) 22.8 (7.01) Median 23.0 25.0 24.0 Range (1; 38) (8;33) (1; 38) Baseline BSS-5 N 31 35 66 Mean (SD) 6.2 (2.61) 7.3 (2.11)6.8 (2.41) Median 7.0 8.0 7.0 Range (1; 10) (2; 10) (1; 10) Baseline BHSTotal Score N 30 35 65 Mean (SD) 15.5 (4.59) 16.5 (2.91) 16.0 (3.79)Median 16.0 17.0 17.0 Range (0; 20) (9; 20) (0; 20) Baseline is definedas the last predose value on Day 1. SIBAT (Module 8) scores are asfollows: 0 = Not suicidal, 1 = Occasional suicidal ideas present, but nospecial intervention required, 2 = Some clear suicidal ideas present,patient is encouraged to schedule professional contacts as needed 3 =Suicidal risk requires a scheduled outpatient follow up; but no otherimmediate intervention, 4 = Suicidal risk requires immediateintervention, but not hospitalization (e.g., medication, urgentoutpatient follow up), 5 = Suicidal risk requires immediatehospitalization, but without suicide precautions, 6 = Suicidal riskrequires hospitalization with suicide precautions.

Extent of Exposure

The number of days dosed is presented in Table 52. More subjects in theesketamine 84 mg group than in the placebo group had all 8 dosingsessions (74.3% vs. 64.5%). The duration of exposure to double-blindmedication is summarized in Table 53. Five subjects reduced their doseof esketamine from 84 mg to 56 mg. Of these, 3 reduced their dose due toan adverse event and 2 had their dose reduced in error and wereconsidered major protocol deviations. In addition, 1 subject had anincorrect med kit number recorded for device 2 on Day 15 so it appearsthat the dose was reduced but in actuality it was not (Table 54).

TABLE 52 Number of Days Dosed with Double-Blind Study Medication (StudyESKETINSUI2001: ITT Analysis Set) Placebo Esketamine 84 mg Number ofDays Dosed (N = 31) (N = 35) 1 1 (3.2%)  4 (11.4%) 2 2 (6.5%) 0 3 0 2(5.7%) 4 1 (3.2%) 0 5 1 (3.2%) 1 (2.9%) 6 3 (9.7%) 1 (2.9%) 7 3 (9.7%) 1(2.9%) 8 20 (64.5%) 26 (74.3%)

TABLE 53 Extent of Exposure During the Double-Blind Phase (StudyESKETINSUI2001: Safety Analysis Set) Placebo Esketamine 84 mg (N = 31)(N = 35) Total Duration, Days N 31 35 Category, n (%)  ≤7 3 (9.7%) 5(14.3%)  8-14 1 (3.2%) 2 (5.7%) 15-21 5 (16.1%) 1 (2.9%) 22-25 14(45.2%) 21 (60.0%) >25 8 (25.8%) 6 (17.1%) Mean (SD) 21.5 (7.22) 20.7(8.49) Median 25.0 25.0 Range (1; 28) (1; 27) The duration of exposureis defined as the duration between the date of the first exposure andthe last date of exposure. It includes days on which subjects did notactually take study medication.

TABLE 54 Number of Subjects who Decreased Their Dose During the Double-Blind Phase (Study ESKETINSUI2001: Safety Analysis Set) Esketamine 84 mgDose Decreased During Double-Blind (N = 35) Yes  6 (17.1%) No 29 (82.9%)Primary Endpoint Analysis—Change from Baseline to Day 1 4-Hours Postdosein MADRS Total Score

The primary efficacy endpoint is the change in MADRS total score frombaseline to Day 1: 4-hours postdose. MADRS total scores range from 0 to60. The primary efficacy analysis was performed on the intent-to-treat(ITT) analysis set, which included all randomized subjects who receivedat least 1 dose of study medication during the double-blind phase andhad both the baseline and the Day 1: 4-hour postdose evaluation for theMADRS total score. As this is a phase 2a proof-of-concept study,statistical significance is based on a two-sided alpha level of 0.20.All p-values presented in this document are two-sided.

As shown in Table 55 below, results for the change in MADRS total scorefavored esketamine 84 mg over placebo. The mean change from baseline(SD) at Day 1: 4-hours postdose was −13.4 (9.03) for esketamine 84 mgand −9.1 (8.38) for placebo. Based on an ANCOVA model with treatment,antidepressant therapy and analysis center as factors and baseline valueas a covariate, the least-square mean difference (SE) between esketamine84 mg and placebo was −5.3 (2.10). The difference between treatmentgroups was statistically significant (two-sided p=0.015) using atwo-sided significance level of 0.20.

TABLE 55 MADRS Total Score: Change from Baseline to Day 1, 4-HourPostdose ANCOVA LOCF Analysis: Double-Blind Phase (Study ESKETINSUI2001:ITT Analysis Set) Placebo Esketamine 84 mg (N = 31) (N = 35)Baseline(DB) N 31 35 Mean (SD) 38.8 (7.02) 38.5 (6.17) Median (Range)40.0 (20; 52) 38.0 (27; 49) Day 1(DB): 4 H N 31 35 Mean (SD) 29.7(11.28) 25.1 (9.67) Median (Range) 30.0 (3; 52) 23.0 (7; 48) Change fromBaseline to Day 1 (DB): 4 H N 31 35 Mean (SD) −9.1 (8.38) −13.4 (9.03)Median (Range) −6.0 (−25; 0) −14.0 (−32; 1) Two-sided p-value 0.015(minus Placebo) ^(a) Diff. of LS Means (SE) −5.3 (2.10) ^(a) Based onanalysis of covariance (ANCOVA) model with treatment (placebo,esketamine 84 mg), antidepressant therapy (AD monotherapy, AD plusaugmentation therapy) and analysis center as factors, and baseline valueas a covariate. Negative change in score indicates improvement. Baselineis the predose, Day 1 value.

Secondary Endpoint Analyses

MADRS Total Score: Change from Baseline to Day 2 (DB) and to End Point(DB)

The results for the change in MADRS total score at Day 2 (DB) are shownin Table 56. The mean change from baseline (SD) was −19.3 (12.02) foresketamine 84 mg and −12.8 (9.77) for placebo. Based on an ANCOVA modelwith treatment, antidepressant therapy and analysis center as factorsand baseline value as a covariate, the esketamine 84 mg group wasstatistically superior to the placebo group (two-sided p-value=0.015)using a two-sided significance level of 0.20. Thus, the changes in MADRStotal score at Day 2 and the Day 25 DB endpoint were statisticallysuperior in the esketamine group compared to the placebo group(two-sided p=0.015 and p=0.159, respectively).

TABLE 56 MADRS Total Score: Change from Baseline to Day 2(DB) ANCOVALOCF Analysis: Double-Blind Phase (Study ESKETINSUI2001: ITT AnalysisSet) Placebo Esketamine 84 mg (N = 31) (N = 35) Baseline(DB) N 31 35Mean (SD) 38.8 (7.02) 38.5 (6.17) Median (Range) 40.0 (20; 52) 38.0 (27;49) Day 2(DB) N 31 35 Mean (SD) 26.0 (12.85) 19.2 (11.23) Median (Range)25.0 (4; 49) 18.0 (3; 42) Change from Baseline to Day 2(DB) N 31 35 Mean(SD) −12.8 (9.77) −19.3 (12.02) Median (Range) −10.0 (−33; 1) −19.0(−41; 1) Two-sided p-value 0.015 (minus Placebo) ^(a) Diff. of LS Means(SE) −7.2 (2.85) ^(a) Based on analysis of covariance (ANCOVA) modelwith treatment (placebo, esketamine 84 mg), antidepressant therapy (ADmonotherapy, AD plus augmentation therapy) and analysis center asfactors, and baseline value as a covariate. Negative change in scoreindicates improvement. Baseline is the predose, Day 1 value.

As shown in Table 57 below, results for the change in MADRS total scoreat End Point (DB) favored esketamine 84 mg over placebo. The mean changefrom baseline (SD) was −26.4 (14.52) for esketamine 84 mg and −23.0(10.83) for placebo. Based on the same ANCOVA model mentioned above, theesketamine 84 mg group was statistically superior to the placebo group(two-sided p-value=0.159) using a two-sided significance level of 0.20.See, FIG. 38.

TABLE 57 MADRS Total Score: Change from Baseline to End Point (DB)ANCOVA LOCF Analysis: Double-Blind Phase (Study ESKETINSUI2001: ITTAnalysis Set) Placebo Esketamine 84 mg (N = 31) (N = 35) Baseline(DB) N31 35 Mean (SD) 38.8 (7.02) 38.5 (6.17) Median (Range) 40.0 (20; 52)38.0 (27; 49) End Point(DB) N 31 35 Mean (SD) 15.8 (12.59) 12.1 (11.90)Median (Range) 14.0 (0; 39) 8.0 (0; 44) Change from Baseline to EndPoint(DB) N 31 35 Mean (SD) −23.0 (10.83) −26.4 (14.52) Median (Range)−21.0 (−42; 1) −25.0 (−46; 13) Two-sided p-value 0.159 (minus Placebo)^(a) Diff. of LS Means (SE) −4.5 (3.14) ^(a) Based on analysis ofcovariance (ANCOVA) model with treatment (placebo, esketamine 84 mg),antidepressant therapy (AD monotherapy, AD plus augmentation therapy)and analysis center as factors, and baseline value as a covariate.Negative change in score indicates improvement. Baseline is the predose,Day 1 value.MADRS Suicide Item: Change from Baseline Over Time

Results of the change from baseline over time for the suicide item fromthe MADRS assessment can be found in Attachment 1. Statisticallysignificant differences favoring esketamine 84 mg were found at Day 1:4-hours postdose (two-sided p=0.002), Day 2 (DB) (two-sided p=0.129) andEnd Point (DB) (two-sided p=0.143).

SIBAT-Clinical Global Judgment of Suicide Risk: Change from Baseline toDay 1: 4-Hours Post Dose, Day 2(DB), and End Point (DB)

The clinical global judgment of suicide risk (Module 8) summarizesclinician overall judgment of suicide risk as derived from informationgathered from the full SIBAT tool. It operates like numerous otherCGI-severity scales that have been used in other psychiatric studies.Change in the clinical global judgment of suicide risk is designed todirectly identify clinical meaningful changes in suicidal ideation andto permit classification of suicide risk.

The analysis of the change in SIBAT score was based on an ANCOVA modelon ranks of change in SIBAT with treatment, antidepressant therapy, andanalysis center as factors, and baseline value (unranked) as acovariate. There was a significant difference (two-sided p-value=0.112)between the two treatment groups when comparing the mean rank of changefrom baseline at Day 1: 4-hours postdose in favor of esketamine 84 mgSee, Table 58. See, FIG. 39. Specifically, the changes in the SIBATClinical Global Judgment of Suicide Risk were statistically superior(i.e., two-sided p<0.2) at Day 1: 4-hours postdose and Day 2 in theesketamine group compared to the placebo group. This difference was notevident at the Day 25 DB endpoint. See, FIG. 40, which is based on LOCFdata and analyzed using Cochran-Mantel-Haenszel test controlling foranalysis center and antidepressant therapy.

TABLE 58 SIBAT Clinical Global Judgment of Suicide Risk: Change fromBaseline to Day 1 4-Hour Post Dose ANCOVA LOCF Analysis: Double- BlindPhase (Study ESKETINSUI2001: ITT Analysis Set) Placebo Esketamine 84 mg(N = 31) (N = 35) Baseline(DB) N 31 35 Median (Range) 5.0 (4; 6) 6.0 (5;6) Day 1(DB): 4 H N 31 33 Median (Range) 5.0 (0; 6) 5.0 (0; 6) Changefrom Baseline to Day 1 (DB): 4 H N 31 33 Median (Range)  0.0 (−5; 1) 0.0 (−6; 1) Two-sided p-value    0.112 (minus Placebo) ^(a) ^(a) Basedon analysis of covariance (ANCOVA) model on ranks of change withtreatment (placebo, esketamine 84 mg), antidepressant therapy (ADmonotherapy, AD plus augmentation therapy) and analysis center asfactors, and baseline value (unranked) as a covariate. Negative changein score indicates improvement. Baseline is the predose, Day 1 value.

As shown in Table 59, similar results were seen for the change frombaseline to Day 2 (DB). Although not shown, at End Point (DB) there wasno statistically significant difference between the treatment groups(two-sided p=0.922).

TABLE 59 SIBAT Clinical Global Judgment of Suicide Risk: Change fromBaseline to Day 2(DB) ANCOVA LOCF Analysis: Double- Blind Phase (StudyESKETINSUI2001: ITT Analysis Set) Placebo Esketamine 84 mg (N = 31) (N =35) Baseline(DB) N 31 35 Median (Range) 5.0 (4; 6) 6.0 (5; 6) Day 2(DB)N 31 35 Median (Range) 5.0 (0; 6) 5.0 (0; 6) Change from Baseline to Day2(DB) N 31 35 Median (Range)  0.0 (−6; 0) −1.0 (−6; 1) Two-sided p-value(minus Placebo) ^(a)    0.150 ^(a) Based on analysis of covariance(ANCOVA) model on ranks of change with treatment (placebo, esketamine 84mg), antidepressant therapy (AD monotherapy, AD plus augmentationtherapy) and analysis center as factors, and baseline value (unranked)as a covariate. Negative change in score indicates improvement. Baselineis the predose, Day 1 value.

For the ITT subjects, the percentage of subjects with a baseline SIBATscore of 5 (Suicidal risk requires immediate hospitalization, butwithout suicide precautions) or 6 (Suicidal risk requireshospitalization with suicide precautions) was 96.8% and 100% for placeboand esketamine 84 mg groups, respectively. At Day 1: 4-hour postdose thepercentage of subjects with a score of 5 or 6 was 80.6% for the placebogroup and 63.6% for the esketamine 84 mg group. The bar chart in FIG. 41shows the frequency distribution of SIBAT scores at double-blindbaseline, Day 1:4-hours postdose, double-blind endpoint, and follow-upendpoint. The bar chart in FIG. 42 shows the least-square mean changes(SE) from baseline in MADRS score to 4 hours (primary endpoint) andabout 24 hours.

Sustained Response (Onset of Clinical Response) in MADRS Total Score

The results for sustained response are shown in Table 60. Sustainedresponse is defined as at least 50% reduction from baseline in MADRStotal score with onset on Day 1: 4 hours postdose that is maintainedthrough the end of the double-blind phase (Day 25). Four subjects in theesketamine 84 mg group and 2 subjects in the placebo group had sustainedresponse throughout the double-blind phase. There was no statisticallysignificant difference between treatment groups (two-sided p=0.608).

TABLE 60 Sustained Response Based on MADRS Total Score (StudyESKETINSUI2001: ITT Analysis Set) Placebo Esketamine 84 mg Day 25sustained response (N = 31) (N = 35) Yes 2 (6.7%)  4 (11.8%) No 28(93.3%) 30 (88.2%) Two-sided p-value (vs. Placebo) ^(a) 0.608Percentages calculated with the number of subjects in each group asdenominator. Sustained response is defined as at least 50 percentreduction from baseline in MADRS total score with onset on Day 1 that ismaintained through the end of the double-blind phase (Day 25). ^(a)Generalized Cochran-Mantel-Haenszel test for mean score difference inbeing a sustained responder controlling for analysis center andantidepressant therapy (AD monotherapy, AD plus augmentation therapy).

FIG. 43 is a bar graph that correlates the percentage of patients withtheir respective MADRS response and remission at days 1, 2 and endpoint.

FIG. 44 is a bar graph that correlates the percentage of patients havingremission at DB endpoint and during follow-up at days 53 and 81.

Beck Scale of Suicidal Ideation (BSS): Change from Baseline to Day 1:4-Hours Post Dose, Day 2 (DB), and End Point (DB)

The BSS is a 21-item self-reported instrument to detect and measure theseverity of suicidal ideation in adults and adolescents aged 17 yearsand older. The BSS total score represents the severity of suicideideation, and it is calculated by summing the ratings of the first 19items; the total score ranges from 0 to 38, with a higher scorerepresenting greater suicide ideation. Increasing scores reflectincreases in suicidal risk.

As shown in Tables 61-63, there were no statistically significantdifferences between esketamine 84 mg and placebo for the change in BSStotal score at Day 1: 4-hours postdose, Day 2 (DB), or End Point (DB),using the same ANCOVA model as described above for MADRS total score.See, FIG. 45.

TABLE 61 BSS Total Score: Change from Baseline to Day 1, 4-Hour PostdoseANCOVA LOCF Analysis: Double-Blind Phase (Study ESKETINSUI2001: ITTAnalysis Set) Placebo Esketamine 84 mg (N = 31) (N = 35) Baseline(DB) N31 34 Mean (SD) 21.4 (8.28) 24.0 (5.45) Median (Range) 23.0 (1; 38) 25.0(8; 33) Day 1 (DB): 4 H N 31 34 Mean (SD) 13.1 (10.12) 13.8 (10.26)Median (Range) 13.0 (0; 36) 16.5 (0; 31) Change from Baseline to Day 1(DB): 4 H N 31 34 Mean (SD) −8.3 (7.12) −10.2 (9.74) Median (Range) −9.0(−27; 2) −8.0 (−33; 8) Two-sided p-value 0.326 (minus Placebo) ^(a)Diff. of LS Means (SE) −2.3 (2.29) ^(a) Based on analysis of covariance(ANCOVA) model with treatment (placebo, esketamine 84 mg),antidepressant therapy (AD monotherapy, AD plus augmentation therapy)and analysis center as factors, and baseline value as a covariate.Negative change in score indicates improvement. Baseline is the predose,Day 1 value.

TABLE 62 BSS Total Score: Change from Baseline to Day 2(DB) ANCOVA LOCFAnalysis: Double-Blind Phase (Study ESKETINSUI2001: ITT Analysis Set)Placebo Esketamine 84 mg (N = 31) (N = 35) Baseline(DB) N 31 34 Mean(SD) 21.4 (8.28) 24.0 (5.45) Median (Range) 23.0 (1; 38) 25.0 (8; 33)Day 2(DB) N 31 34 Mean (SD) 10.6 (9.71) 11.1 (10.12) Median (Range) 9.0(0; 36) 13.0 (0; 34) Change from Baseline to Day 2(DB) N 31 34 Mean (SD)−10.7 (7.73) −12.9 (9.63) Median (Range) −10.0 (−31; 0) −11.5 (−33; 2)Two-sided p-value 0.415 (minus Placebo) ^(a) Diff. of LS Means (SE) −1.9(2.30) ^(a) Based on analysis of covariance (ANCOVA) model withtreatment (placebo, esketamine 84 mg), antidepressant therapy (ADmonotherapy, AD plus augmentation therapy) and analysis center asfactors, and baseline value as a covariate. Negative change in scoreindicates improvement. Baseline is the predose, Day 1 value.

TABLE 63 BSS Total Score: Change from Baseline to End Point (DB) ANCOVALOCF Analysis: Double-Blind Phase (Study ESKETINSUI2001: ITT AnalysisSet) Placebo Esketamine 84 mg (N = 31) (N = 35) Baseline(DB) N 31 34Mean (SD) 21.4 (8.28) 24.0 (5.45) Median (Range) 23.0 (1; 38) 25.0 (8;33) End Point(DB) N 31 34 Mean (SD) 5.4 (7.74) 4.7 (9.03) Median (Range)0.0 (0; 23) 0.0 (0; 34) Change from Baseline to End Point(DB) N 31 34Mean (SD) −16.0 (10.54) −19.3 (9.61) Median (Range) −17.0 (−38; 3) −21.0(−33; 8) Two-sided p-value 0.431 (minus Placebo) ^(a) Diff. of LS Means(SE) −1.7 (2.15) ^(a) Based on analysis of covariance (ANCOVA) modelwith treatment (placebo, esketamine 84 mg), antidepressant therapy (ADmonotherapy, AD plus augmentation therapy) and analysis center asfactors, and baseline value as a covariate. Negative change in scoreindicates improvement. Baseline is the predose, Day 1 value.Beck Hopelessness Scale (BHS): Change from Baseline to Day 1: 4-HoursPost Dose and End Point (DB)

The BHS is a self-reported measure to assess one's level of negativeexpectations or pessimism regarding the future. It consists of 20true-false items that examine the respondent's attitude over the pastweek by either endorsing a pessimistic statement or denying anoptimistic statement. For every statement, each response is assigned ascore of 0 or 1. The total BHS score is a sum of item responses andranges from 0 to 20, with a higher score representing a higher level ofhopelessness.

As shown in Table 64, there was no statistically significant differencebetween esketamine 84 mg and placebo for the change in BHS total scoreat Day 1: 4-hours postdose (two-sided p=0.297). However, at End Point(DB) esketamine 84 mg was statistically superior (two-sided p=0.165) toplacebo using a two-sided significance level of 0.20. (Table 65).

TABLE 64 BHS Total Score: Change from Baseline to Day 1, 4-Hour PostdoseANCOVA LOCF Analysis: Double-Blind Phase (Study ESKETINSUI2001: ITTAnalysis Set) Placebo Esketamine 84 mg (N = 31) (N = 35) Baseline(DB) N30 35 Mean (SD) 15.5 (4.59) 16.5 (2.91) Median (Range) 16.0 (0; 20) 17.0(9; 20) Day 1(DB): 4 H N 30 35 Mean (SD) 12.4 (7.12) 12.3 (6.95) Median(Range) 14.5 (0; 20) 14.0 (0; 20) Change from Baseline to Day 1 (DB): 4H N 30 35 Mean (SD) −3.1 (5.71) −4.1 (5.63) Median (Range) 0.0 (−18; 4)−2.0 (−16; 2) Two-sided p-value 0.297 (minus Placebo) ^(a) Diff. of LSMeans (SE) −1.5 (1.47) ^(a) Based on analysis of covariance (ANCOVA)model with treatment (placebo, esketamine 84 mg), antidepressant therapy(AD monotherapy, AD plus augmentation therapy) and analysis center asfactors, and baseline value as a covariate. Negative change in scoreindicates improvement. Baseline is the predose, Day 1 value.

TABLE 65 BHS Total Score: Change from Baseline to End Point (DB) ANCOVALOCF Analysis: Double-Blind Phase (Study ESKETINSUI2001: ITT AnalysisSet) Placebo Esketamine 84 mg (N = 31) (N = 35) Baseline(DB) N 30 35Mean (SD) 15.5 (4.59) 16.5 (2.91) Median (Range) 16.0 (0; 20) 17.0 (9;20) End Point(DB) N 30 35 Mean (SD) 7.8 (7.16) 6.2 (5.96) Median (Range)4.5 (0; 20) 4.0 (0; 20) Change from Baseline to End Point(DB) N 30 35Mean (SD) −7.7 (7.81) −10.3 (5.51) Median (Range) −9.0 (−20; 8) −11.0(−19; 0) Two-sided p-value 0.165 (minus Placebo) ^(a) Diff. of LS Means(SE) −2.3 (1.66) ^(a) Based on analysis of covariance (ANCOVA) modelwith treatment (placebo, esketamine 84 mg), antidepressant therapy (ADmonotherapy, AD plus augmentation therapy) and analysis center asfactors, and baseline value as a covariate. Negative change in scoreindicates improvement. Baseline is the predose, Day 1 value.

Safety Summary of All Adverse Events

An overall summary of all treatment-emergent adverse events (TEAEs)during the double-blind phase is presented in Table 66. Overall, 80.6%of subjects in the placebo group and 94.3% of subjects in the esketamine84 mg group experienced at least one TEAE during the double-blind phase.

Overall, 33/35 (94.3%) of subjects who received esketamine 84 mg and25/31 (80.6%) of subjects who received placebo experienced at least onetreatment-emergent adverse event (TEAE) during the double-blind phase.

TABLE 66 Overall Summary of Treatment-Emergent Adverse Events Double-Blind Phase (Study ESKETINSUI2001: Safety Analysis Set) PlaceboEsketamine 84 mg (N = 31) (N = 35) TEAE 25 (80.6%) 33 (94.3%) Possiblyrelated TEAE ^(a) 12 (38.7%) 29 (82.9%) TEAE leading to death 0 0 1 ormore serious TEAE 0  4 (11.4%) TEAE leading to drug withdrawn 1 (3.2%) 5 (14.3%) ^(a) Study drug relationships of possible, probable, and verylikely are included in this category. Incidence is based on the numberof subjects experiencing at least one adverse event, not the number ofevents. Adverse events are coded using MedDRA version 18.0

Treatment-emergent adverse events occurring during the double-blindphase (≥5% of subjects in any treatment group) are summarized bytreatment group for safety analysis set in Table 67. The most common(≥20%) TEAEs in the esketamine 84 mg group during the double-blind phasewere nausea (37.1%), dizziness (34.3%), dysgeusia (31.4%), headache(31.4%), dissociation (31.4%) and vomiting (20.0%). The most common TEAEin the placebo group was headache (25.8%).

TABLE 67 Treatment-Emergent Adverse Events in ≥5% of Subjects in AnyTreatment Group: Double-Blind Phase (Study ESKETINSUI2001: SafetyAnalysis Set) Placebo Esketamine 84 mg (N = 31) (N = 35) Total no.subjects with TEAE 25 (80.6%) 33 (94.3%) Nervous system disorders 16(51.6%) 25 (71.4%) Dizziness 4 (12.9%) 12 (34.3%) Dysgeusia 5 (16.1%) 11(31.4%) Headache 8 (25.8%) 11 (31.4%) Paresthesia 1 (3.2%) 6 (17.1%)Sedation 2 (6.5%) 6 (17.1%) Somnolence 2 (6.5%) 4 (11.4%) Hypoesthesia 03 (8.6%) Dizziness postural 0 2 (5.7%) Psychiatric disorders 10 (32.3%)20 (57.1%) Dissociation 4 (12.9%) 11 (31.4%) Anxiety 1 (3.2%) 6 (17.1%)Euphoric mood 2 (6.5%) 4 (11.4%) Agitation 0 3 (8.6%) Insomnia 2 (6.5%)3 (8.6%) Suicidal ideation 0 2 (5.7%) Panic attack 2 (6.5%) 0Gastrointestinal disorders 11 (35.5%) 19 (54.3%) Nausea 1 (3.2%) 13(37.1%) Vomiting 0 7 (20.0%) Diarrhea 0 3 (8.6%) Dry mouth 0 3 (8.6%)Hypoesthesia oral 0 2 (5.7%) Paresthesia oral 0 2 (5.7%) Flatulence 2(6.5%) 1 (2.9%) Abdominal pain 2 (6.5%) 0 Constipation 3 (9.7%) 0Toothache 2 (6.5%) 0 General disorders and 2 (6.5%) 10 (28.6%)administration site conditions Feeling abnormal 0 3 (8.6%) Fatigue 1(3.2%) 2 (5.7%) Feeling cold 0 2 (5.7%) Ear and labyrinth disorders 1(3.2%) 9 (25.7%) Vertigo 0 4 (11.4%) Hyperacusis 0 2 (5.7%) Tinnitus 0 2(5.7%) Respiratory, thoracic and mediastinal 8 (25.8%) 9 (25.7%)disorders Nasal discomfort 1 (3.2%) 3 (8.6%) Throat irritation 0 3(8.6%) Oropharyngeal pain 1 (3.2%) 2 (5.7%) Pharyngeal hypoesthesia 0 2(5.7%) Nasal congestion 2 (6.5%) 1 (2.9%) Epistaxis 2 (6.5%) 0Intranasal paranesthesia 2 (6.5%) 0 Rhinalgia 2 (6.5%) 0 Rhinorrhoea 2(6.5%) 0 Eye disorders 2 (6.5%) 7 (20.0%) Vision blurred 0 3 (8.6%)Diplopia 0 2 (5.7%) Blepharospasm 2 (6.5%) 0 Investigations 1 (3.2%) 5(14.3%) Blood pressure increased 0 2 (5.7%) Weight increased 0 2 (5.7%)Skin and subcutaneous tissue 4 (12.9%) 5 (14.3%) disorders Acne 0 2(5.7%) Hyperhidrosis 0 2 (5.7%) Rash 3 (9.7%) 1 (2.9%) Infections andinfestations 4 (12.9%) 1 (2.9%) Upper respiratory tract infection 2(6.5%) 0 Renal and urinary disorders 2 (6.5%) 1 (2.9%) Pollakiuria 2(6.5%) 0 Incidence is based on the number of subjects experiencing atleast one adverse event, not the number of events. Adverse events arecoded using MedDRA version 18.0

Adverse events occurring during the follow up phase are summarized inTable 68. In total, 77.3% subjects in the placebo group and 48.1%subjects in the esketamine 84 mg group experienced at least one adverseevent during the follow u phase.

TABLE 68 Adverse Events by MedDRA System Organ Class and Preferred Term:Follow up Phase (Study ESKETINSUI2001: Safety (FU) Analysis Set) PlaceboEsketamine 84 mg (N = 22) (N = 27) Total no. subjects with adverseevents 17 (77.3%) 13 (48.1%) Gastrointestinal disorders 4 (18.2%) 6(22.2%) Dry mouth 0 2 (7.4%) Abdominal pain 0 1 (3.7%) Abdominaltenderness 0 1 (3.7%) Diarrhea 0 1 (3.7%) Vomiting 0 1 (3.7%) Aphthousulcer 1 (4.5%) 0 Nausea 1 (4.5%) 0 Tooth impacted 1 (4.5%) 0 Toothache 1(4.5%) 0 Nervous system disorders 3 (13.6%) 6 (22.2%) Headache 2 (9.1%)2 (7.4%) Tremor 0 2 (7.4%) Cogwheel rigidity 0 1 (3.7%) Dizziness 0 1(3.7%) Dysgeusia 0 1 (3.7%) Loss of consciousness 0 1 (3.7%) Migraine 01 (3.7%) Sedation 0 1 (3.7%) Somnolence 1 (4.5%) 0 Psychiatric disorders8 (36.4%) 5 (18.5%) Insomnia 0 3 (11.1%) Depression 1 (4.5%) 1 (3.7%)Intentional self-injury 0 1 (3.7%) Restlessness 0 1 (3.7%) Suicidalideation 1 (4.5%) 1 (3.7%) Depressed mood 1 (4.5%) 0 Panic reaction 1(4.5%) 0 Self-injurious ideation 1 (4.5%) 0 Suicide attempt 3 (13.6%) 0Infections and infestations 8 (36.4%) 3 (11.1%) Pharyngitis 0 2 (7.4%)Ear infection 0 1 (3.7%) Nasopharyngitis 1 (4.5%) 1 (3.7%) Upperrespiratory tract infection 1 (4.5%) 1 (3.7%) Vulvovaginal mycoticinfection 0 1 (3.7%) Bronchitis 1 (4.5%) 0 Cellulitis 3 (13.6%) 0Folliculitis 1 (4.5%) 0 Influenza 1 (4.5%) 0 Viral upper respiratorytract infection 1 (4.5%) 0 Injury, poisoning and procedural 1 (4.5%) 2(7.4%) complications Contusion 0 1 (3.7%) Road traffic accident 0 1(3.7%) Procedural pain 1 (4.5%) 0 Musculoskeletal and connective 1(4.5%) 2 (7.4%) tissue disorders Back pain 0 1 (3.7%) Flank pain 0 1(3.7%) Musculoskeletal chest pain 0 1 (3.7%) Musculoskeletal pain 0 1(3.7%) Neck pain 1 (4.5%) 1 (3.7%) Respiratory, thoracic and mediastinal0 2 (7.4%) disorders Epistaxis 0 1 (3.7%) Nasal congestion 0 1 (3.7%)Reproductive system and breast 1 (4.5%) 1 (3.7%) disorders Pelvic pain 01 (3.7%) Sexual dysfunction 1 (4.5%) 0 Skin and subcutaneous tissue 1(4.5%) 1 (3.7%) disorders Night sweats 0 1 (3.7%) Rash 1 (4.5%) 0 Earand labyrinth disorders 1 (4.5%) 0 Meniere's disease 1 (4.5%) 0 Immunesystem disorders 1 (4.5%) 0 Drug hypersensitivity 1 (4.5%) 0 Metabolismand nutrition disorders 1 (4.5%) 0 Polydipsia 1 (4.5%) 0 Renal andurinary disorders 1 (4.5%) 0 Renal failure 1 (4.5%) 0 Incidence is basedon the number of subjects experiencing at least one adverse event, notthe number of events. Adverse events are coded using MedDRA version 18.0

Deaths

There were no deaths.

Adverse Events Leading to Study Drug Withdrawal

There were 6 subjects (1 subject in the placebo group and 5 subjects inthe esketamine 84 mg group) who discontinued from the double-blind phasedue to treatment-emergent adverse events. See, Table 69.

TABLE 69 Treatment-Emergent Adverse Events Leading to StudyDiscontinuation: Double-Blind Phase (Study ESKETINSUI2001: SafetyAnalysis Set) Placebo Esketamine 84 mg (N = 31) (N = 35) Total no.subjects with TEAE leading to 1 (3.2%)  5 (14.3%) study discontinuationNervous system disorders 0 2 (5.7%) Dizziness 0 1 (2.9%) Dysgeusia 0 1(2.9%) Psychiatric disorders 1 (3.2%) 2 (5.7%) Aggression 0 1 (2.9%)Agitation 0 1 (2.9%) Dissociative disorder 1 (3.2%) 0 Panic attack 1(3.2%) 0 Cardiac disorders 0 1 (2.9%) Ventricular extrasystoles 0 1(2.9%) Gastrointestinal disorders 0 1 (2.9%) Nausea 0 1 (2.9%)Respiratory, thoracic and mediastinal 0 1 (2.9%) disorders Dyspnea 0 1(2.9%) Incidence is based on the number of subjects experiencing atleast one adverse event, not the number of events. Adverse events arecoded using MedDRA version 18.0

Serious Adverse Events

Four subjects experienced a serious treatment-emergent adverse eventduring the double-blind phase and all were in the esketamine 84 mg group(Table 70). Two subjects experienced suicidal ideation, 1 subjectexperienced agitation, and 1 subject experienced depressive symptoms.One placebo subject experienced serious major depressive disorderaggravated post double-blind phase after discontinuing from the study.This subject did not participate in the follow up phase.

TABLE 70 Treatment-Emergent Serious Adverse Events: Double-Blind Phase(Study ESKETINSUI2001: Safety Analysis Set) Placebo Esketamine 84 mg (N= 31) (N = 35) Total no. subjects with a serious TEAE 0  4 (11.4%)Psychiatric disorders 0  4 (11.4%) Suicidal ideation 0 2 (5.7%)Agitation 0 1 (2.9%) Depressive symptom 0 1 (2.9%) Incidence is based onthe number of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 18.0

As shown in Table 71, 6 subjects experienced a serious adverse event inthe follow up phase (5 in the placebo group and 1 in the esketamine 84mg group).

TABLE 71 Serious Adverse Events: Follow up Phase (Study ESKETINSUI2001:Safety (FU) Analysis Set) Placebo Esketamine 84 mg (N = 22) (N = 27)Total no. subjects with a serious 5 (22.7%) 1 (3.7%) adverse eventPsychiatric disorders 4 (18.2%) 1 (3.7%) Suicidal ideation 1 (4.5%) 1(3.7%) Suicide attempt 3 (13.6%) 0 Infections and infestations 1 (4.5%)0 Cellulitis 1 (4.5%) 0 Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 18.0

Vital Signs

Transient blood pressure increases peaked for the esketamine group atapproximately 40 minutes post dose with the maximum mean increases(across all dosing days) in systolic BP being 8.7 in the placebo groupand 16.7 in the esketamine 84 mg group. The maximum mean increases(across all dosing days) in diastolic BP were 7.6 in the placebo groupand 11.9 in the esketamine 84 mg group. In summary, transient bloodpressure increases, typically returning to normal range by 2 hours postdose, were observed in the esketamine group. See, FIGS. 46 and 47.

Other Safety Observations Clinician-Assessed Dissociative Symptom Scale(CADSS)

The CADSS was measured prior to the start of each dose, at 40 minutes, 2hours, and 4 hours postdose. The CADSS is used to assess treatmentemergent dissociative symptoms and perceptual changes and the totalscore ranges from 0 to 92 with a higher score representing a more severecondition.

The dissociative and perceptual change symptoms measured by the CADSS,suggest these symptoms had an onset shortly after the start of the doseand resolved by 2 hours postdose (FIG. 55). See, Tables 72A and 72B.

TABLE 72A MADRS Suicide Item: Medians and Median Changes Over TimeDuring the Double-Blind and Follow up Phases (Study ESKETINSUI2001: ITTAnalysis Set) Placebo Change from Baseline Suicidal Thoughts N Med MinMax Med Min Max Baseline(DB) 31 5.0 3 6 Day 1(DB): 4 H 31 4.0 0 6 −1.0−6 0 Day 2(DB) 31 2.0 0 5 −2.0 −6 0 Day 3(DB) 31 2.0 0 5 −3.0 −6 0 Day4(DB) 25 2.0 0 5 −2.0 −6 0 Day 5(DB) 10 1.5 0 5 −4.0 −6 0 Day 8(DB) 292.0 0 5 −3.0 −6 1 Day 11(DB) 26 1.5 0 4 −4.0 −6 0 Day 15(DB) 25 1.0 0 4−4.0 −6 −1 Day 18(DB) 26 1.0 0 5 −4.0 −6 0 Day 22(DB) 25 1.0 0 5 −4.0 −62 Day 25(DB): Predose 22 1.0 0 4 −4.0 −6 −1 Day 25(DB): 4 H 24 0.0 0 4−4.0 −6 −1 Day 32(FU) 22 0.0 0 5 −4.0 −6 0 Day 39(FU) 21 0.0 0 4 −4.0 −6−1 Day 46(FU) 20 0.5 0 4 −4.0 −6 −1 Day 53(FU) 20 0.0 0 4 −4.0 −6 −2 Day67(FU) 19 0.0 0 2 −5.0 −6 −3 Day 81 (FU) 20 0.5 0 3 −4.0 −6 −2 Day1(DB): 4 H LOCF 31 4.0 0 6 −1.0 −6 0 Day 2(DB) LOCF 31 2.0 0 5 −2.0 −6 0Day 3(DB) LOCF 31 2.0 0 5 −3.0 −6 0 Day 4(DB) LOCF 31 2.0 0 5 −3.0 −6 0Day 5(DB) LOCF 31 2.0 0 5 −2.0 −6 0 Day 8(DB) LOCF 31 2.0 0 5 −3.0 −6 1Day 11(DB) LOCF 31 2.0 0 4 −4.0 −6 0 Day 15(DB) LOCF 31 1.0 0 4 −4.0 −60 Day 18(DB) LOCF 31 2.0 0 5 −4.0 −6 0 Day 22(DB) LOCF 31 2.0 0 5 −4.0−6 2 Day 25(DB): Predose 31 1.0 0 5 −4.0 −6 2 LOCF End Point(DB) 31 0.00 4 −4.0 −6 0 Day 32(FU) LOCF 22 0.0 0 5 −4.0 −6 0 Day 39(FU) LOCF 220.0 0 4 −4.0 −6 −1 Day 46(FU) LOCF 22 0.0 0 4 −4.0 −6 −1 Day 53(FU) LOCF22 0.0 0 4 −4.0 −6 −2 Day 67(FU) LOCF 22 0.0 0 2 −4.5 −6 −3 EndPoint(FU) 22 0.5 0 3 −4.0 −6 −2 ^(a) Test for no difference betweentreatments from ANCOVA model on ranks of change with factor(s) fortreatment, antidepressant therapy (AD monotherapy, AD plus augmentationtherapy) and analysis center with baseline value (unranked) as acovariate.

TABLE 72B MADRS Suicide Item: Medians and Median Changes Over TimeDuring the Double- Blind and Follow up Phases (Study ESKETINSUI2001: ITTAnalysis Set) Esketamine 84 mg- Suicidal Esketamine 84 mg Change fromBaseline Placebo Thoughts N Med Min Max Med Min Max P-value Baseline(DB)35 5.0 3 6 Day 1(DB): 4 H 35 2.0 0 6 −3.0 −5 1 0.002 Day 2(DB) 35 2.0 06 −3.0 −6 1 0.129 Day 3(DB) 32 2.0 0 6 −4.0 −6 1 0.183 Day 4(DB) 24 1.00 5 −4.0 −6 1 0.010 Day 5(DB) 21 0.0 0 6 −4.0 −6 1 0.423 Day 8(DB) 311.0 0 6 −4.0 −6 1 0.205 Day 11(DB) 25 0.0 0 6 −4.0 −6 1 0.077 Day 15(DB)29 1.0 0 5 −4.0 −6 1 0.440 Day 18(DB) 23 1.0 0 6 −4.0 −6 1 0.583 Day22(DB) 28 0.0 0 5 −4.0 −6 1 0.328 Day 25(DB): 24 0.0 0 6 −4.5 −6 2 0.260Predose Day 25(DB): 4 H 24 0.0 0 6 −4.5 −6 2 0.426 Day 32(FU) 26 0.0 0 6−4.0 −6 2 0.635 Day 39(FU) 26 0.0 0 5 −5.0 −6 1 0.274 Day 46(FU) 25 0.00 5 −4.0 −6 1 0.830 Day 53(FU) 24 0.0 0 5 −5.0 −6 1 0.933 Day 67(FU) 260.0 0 5 −4.0 −6 1 0.323 Day 81(FU) 24 0.0 0 5 −5.0 −6 1 0.527 Day 1(DB):4 H 35 2.0 0 6 −3.0 −5 1 0.002 LOCF Day 2(DB) LOCF 35 2.0 0 6 −3.0 −6 10.129 Day 3(DB) LOCF 35 2.0 0 6 −4.0 −6 1 0.136 Day 4(DB) LOCF 35 1.0 06 −4.0 −6 1 0.049 Day 5(DB) LOCF 35 1.0 0 6 −4.0 −6 1 0.003 Day 8(DB)LOCF 35 1.0 0 6 −4.0 −6 1 0.170 Day 11(DB) LOCF 35 1.0 0 6 −4.0 −6 10.037 Day 15(DB) LOCF 35 1.0 0 5 −4.0 −6 1 0.128 Day 18(DB) LOCF 35 1.00 6 −4.0 −6 1 0.093 Day 22(DB) LOCF 35 0.0 0 5 −4.0 −6 1 0.059 Day25(DB): 35 0.0 0 6 −4.0 −6 2 0.058 Predose LOCF End Point(DB) 35 0.0 0 6−4.0 −6 2 0.143 Day 32(FU) LOCF 26 0.0 0 6 −4.0 −6 2 0.635 Day 39(FU)LOCF 27 0.0 0 5 −5.0 −6 1 0.211 Day 46(FU) LOCF 27 0.0 0 5 −4.0 −6 10.589 Day 53(FU) LOCF 27 0.0 0 5 −4.0 −6 1 0.959 Day 67(FU) LOCF 27 0.00 5 −4.0 −6 1 0.296 End Point(FU) 27 0.0 0 5 −5.0 −6 1 0.497 ^(a) Testfor no difference between treatments from ANCOVA model on ranks ofchange with factor(s) for treatment, antidepressant therapy (ADmonotherapy, AD plus augmentation therapy) and analysis center withbaseline value (unranked) as a covariate.

In summary, dissociative symptoms, as measured on the CADSS, observed inthe esketamine group were consistent with prior studies. These symptomswere transient (resolved within 2 hrs) and attenuated with repeateddosing.

Summary

Intranasal esketamine 84 mg, compared to placebo, demonstrated aclinically meaningful and statistically significant rapid reduction ofdepressive symptoms in subjects with MDD who are assessed to be atimminent risk for suicide, as demonstrated by change from baseline inthe MADRS total score at both 4 hours and Day 2. Significant improvementin suicidality was also observed at 4 hours and Day 2 as measured byboth the MADRS suicide item and the SIBAT Clinical Global Judgment ofSuicide Risk. There was no difference detected on the BSS at any ofthese time points. As observed in previous esketamine studies in TRD,the perceptual (dissociative) symptoms measured by the CADSS and BPelevation, appear to occur shortly after the start of the administrationand resolved by 2 hours post administration. Additionally, perceptualsymptoms attenuated with repeated dosing. Of note, during the follow upperiod 3 subjects in the placebo group, but none in the esketaminegroup, made suicide attempts (non-fatal).

The results of the Phase 2a POC study supports the hypothesis thatintranasal esketamine is an efficacious treatment for the rapidreduction of the symptoms of MDD, including suicidal ideation, inpatients assessed to be at imminent risk for suicide. The subjectsincluded in this study were severely depressed and suicidal as evidencedby their high baseline MADRS and BSS scores. All subjects were treatedaggressively with initial hospitalization and optimized standard of careantidepressant medication. Therefore, it is not surprising that,subjects in both treatment groups experienced clinically meaningfulimprovement in all efficacy measures over the course of the double-blindperiod. Despite the non-specific improvement in the placebo group, thebeneficial effect of esketamine on the symptoms of MDD, as measured bythe MADRS total score and the MADRS suicide item, could be distinguishedat early time points and at the double-point end-point.

Example 4

The primary objective of this study is to assess the efficacy ofintranasal esketamine plus an oral antidepressant compared with an oralantidepressant plus intranasal placebo in delaying relapse of depressivesymptoms in subjects with TRD who have achieved stable remission(primary) or stable response (secondary) after an induction andoptimization course of intranasal esketamine plus an oral antidepressant(AD), to assess the efficacy of esketamine plus an oral AD compared withan oral AD plus intranasal placebo in delaying relapse of depressivesymptoms. A key question addressed was whether in the stableremitter/responder groups, esketamine could be stopped and longer-termmaintenance be achieved with the oral AD alone. A relapse adjudicationcommittee reviewed events that were considered clinically relevant todetermine if a relapse occurred.

Together with the 3 short-term efficacy and safety studies and the longterm open label safety study, this study supports regulatory agencyrequirements for registration of esketamine nasal spray for thetreatment of TRD.

Subject and Treatment Information

This was a randomized, double-blind, parallel-group, active-controlled,multicenter study that included 705 enrolled subjects with TRD. Thisstudy evaluated the efficacy, safety, and tolerability of intranasalesketamine plus an oral antidepressant compared with an oralantidepressant plus intranasal placebo in delaying relapse of depressivesymptoms in adult men and women with TRD who are in stable remissionafter an induction and optimization phase treatment with intranasalesketamine plus an oral antidepressant. See, FIG. 49 for the trialdesign.

Of the 705 enrolled subjects, 437 (62.0%) were directly enrolled intothe 3003 study, 150 (21.3%) were transferred from the ESKETINTRD3001study, and 118 (16.7%) were transferred from the ESKETINTRD3002 study.See, FIG. 50. In the all enrolled analysis set, 635 (90.1%) of thesubjects were white and 457 (64.8%) of the subjects were female. Themean age was 46.1 years, ranging from 18 to 64 years. Of the 437 safety(IND) analysis set subjects (direct-entry subjects only), 273 (62.5%)subjects completed the 28-day IND phase and 164 (37.5%) withdrew. Themajority of subjects were discontinued from the IND phase due tosubjects who did not meet criteria for continuing into the next phase’(114 subjects).

Of the 455 esketamine-treated subjects entering the OP phase (including182 esketamine-treated transferred-entry subjects from the TRD3001 orTRD3002 study), 297 (65.3%) subjects completed the 12-week OP phase and158 (34.7%) subjects withdrew. The most frequent reasons fordiscontinuation were due to subject did not meet criteria for continuinginto the next phase (107 subjects).

Of the 176 subjects in the full (stable remitters) analysis set, 159(90.3%) subjects completed the MA phase (of those, 63 (35.8%) had arelapse event and 96 (54.5%) remained relapse-free at the time of thestudy termination). The most frequent reason for withdrawal was ‘other’(8 subjects).

Of the 121 subjects in the full (stable responders) analysis set, 113(93.4%) subjects completed the MA phase (of those, 50 (41.3%) had arelapse event and 63 (52.1%) remained relapse-free at the time of thestudy termination). The most frequent reason for withdrawal was‘withdrawal by subject’ (3 subjects). A total of 545 subjected enteredthe follow-up phase and 532 (97.6%) completed the follow-up phase.

Subjects presented at baseline (IND) with a median MADRS total score of38, (severe depression) and the median duration of the currentdepressive episode was 64 weeks, with 27.4% having a lifetime history ofsuicidal ideation (29.1% in the past 6 months) and a 14.9% lifetimehistory of suicidal behavior. Over 89.0% of subjects had received 3 ormore ADs with non-response (defined as ≤25% improvement) prior tostarting the Induction phase. Subjects reported a family history ofdepression (45.1%), anxiety disorder (9.1%), and alcohol abuse (13.5%).

Treatment duration/Trial duration: Each subject participated in up to 5phases: a screening prospective observational phase (direct-entrysubjects only) of 4 weeks+an optional up to 3-week taper period, a4-week open-label induction phase (direct-entry subjects only), a12-week optimization phase (open-label for direct-entry subjects anddouble-blind for transferred-entry subjects), a double-blind maintenancephase of variable duration and a 2-week follow-up phase. The maximumduration of a subject's participation was variable, depending on whetherhe or she entered the study directly or was transferred from one of thedouble-blind short-term studies, and whether he or she metphase-specific criteria (e.g., met criteria for response at the end ofthe induction phase, was in stable remission/response at the end of theoptimization phase, and when and if he or she relapsed in themaintenance phase). Direct-entry subjects participated in up to 5 phasesand transferred-entry subjects participated in up to 3 phases in thecurrent study after having participated in the screening prospectiveobservational and Induction phases in the studies they transferred from.The inclusion/exclusion criteria were the same for direct and transferentry subjects.

Efficacy Level of Significance

A pre-planned interim analysis of efficacy data was conducted when 33relapse events occurred in stable remitters with at least 30 relapses(31 were actually included in the interim analysis) from randomizedstable remitters treated with intranasal esketamine plus an oralantidepressant in the optimization phase (List 1). The objectives of theinterim analysis were to re-estimate sample size or to stop the studyfor efficacy. An independent external statistical support group (Cytel)conducted the analysis and the IDMC reviewed unblinded results andrecommended to continue the study. Based on the predefined rules, thefinal sample size determined from the sample size re-estimation was 59.The Janssen team and the sites remained blinded to the IDMC sample sizerecommendation until 59 relapses had occurred in the List 1 subjects.

The interim efficacy analysis was performed at a significance level of0.0097 (two-sided). As the study was not stopped for efficacy at theinterim analysis, the final efficacy analysis was to be performed at asignificance level of 0.046 (two-sided).

Primary Endpoint

The primary efficacy analysis was performed on the full (stableremitters) analysis set, which included 175 stable remitters and 1stable responder (who was incorrectly randomized as a stable remitter)which is defined as randomized subjects who were in stable remission atthe end of the optimization phase after treatment with intranasalesketamine plus an oral antidepressant. The subjects were randomized asstable remitters (List 1) in a 1:1 ratio to continue on intranasalesketamine plus oral AD (N=90) or to discontinue esketamine and receiveoral AD plus intranasal placebo (N=86); These subjects received at least1 dose of intranasal study drug and 1 dose of oral antidepressant duringthe maintenance phase.

Results for the time to relapse in the maintenance phase favoredintranasal esketamine+oral AD in delaying relapse compared to oral AD+intranasal placebo. Overall, 24 (26.7%) subjects in the intranasalesketamine+oral AD group and 39 (45.3%) subjects in the oral AD+intranasal placebo group experienced a relapse event during themaintenance phase. Based on the weighted combination test, thedifference between treatment groups was statistically significant(two-sided p=0.003), which was below the threshold of statisticalsignificance (0.046). The estimated hazard ratio of intranasalesketamine+oral AD relative to oral AD+ intranasal placebo based onweighted estimates was 0.49 (95% CI: 0.29, 0.84) using ADDPLAN. The mostcommon reason for relapse was a MADRS total score ≥22 for 2 consecutiveassessments separated by 5 to 15 days.

No major differences in efficacy were seen by region, gender, age,direct or transfer entry, or oral AD group (SNRIs and SSRIs).

Other Secondary Efficacy Endpoints

Secondary efficacy variables included:

-   -   The time between subject randomization and the first        documentation (earliest date) of a relapse in the maintenance        phase for subjects with stable response (but who were not in        remission) at the end of the optimization phase after treatment        with intranasal esketamine plus an oral antidepressant.    -   Change in MADRS from Baseline (MA) to End Point (MA)    -   Proportion of subjects with response and remission based on        MADRS    -   Change in PHQ-9 from Baseline (MA) to End Point (MA)    -   Change in CGI-S from Baseline (MA) to End Point (MA)    -   Change in GAD-7 from Baseline (MA) to End Point (MA)    -   Change in EQ-5D-5L from Baseline (MA) to End Point (MA)    -   Change in SDS from Baseline (MA) to End Point (MA)

Results for the time between subject randomization and the firstdocumentation (earliest date) of a relapse in the maintenance phase forsubjects in the full (stable responders) analysis set (including 121subjects: 120 stable responders and 1 subject not meeting either stableremission or stable response criteria at the end of the optimizationphase) after treatment with intranasal esketamine plus an oralantidepressant favored intranasal esketamine+oral AD in delaying relapsecompared to oral AD+ intranasal placebo. Overall, 16 (25.8%) subjects inthe intranasal esketamine+oral AD group and 34 (57.6%) subjects in theoral AD+ intranasal placebo group experienced a relapse event duringmaintenance phase. The difference between treatment groups wasstatistically significant (two-sided p<0.001) using a two-sided log-ranktest. The estimated hazard ratio of intranasal esketamine+oral ADrelative to oral AD+ intranasal placebo based on the Cox proportionalhazards model with treatment as a factor was 0.30 (95% CI: 0.16, 0.55).

The subjects were randomized as stable responders (List 2) in a 1:1ratio to continue on intranasal esketamine plus oral AD (N=62) or todiscontinue esketamine and receive oral AD plus intranasal placebo(N=59). Both randomization lists were stratified by country.

Safety

Overall, 76.9% of subjects experienced at least one TEAE during the INDphase. In the safety (OP) analysis set (safety (OP) and safety (MA)analysis sets do not include the transferred-entry subjects whocontinued to receive oral AD+placebo (TEP) during the subsequentphases), 73.6% of subjects experienced at least one TEAE during the OPphase. In the safety (MA) analysis set, 82.2% of subjects in theesketamine+oral AD group and 45.5% of subjects in the oral AD+placebogroup experienced at least one TEAE during the MA phase. For the TEPsubjects, 61.6% of subjects experienced at least one TEAE during the OPphase and 68.5% experienced at least one TEAE during the MA phase.

The most common TEAEs (≥10%) during the IND phase were vertigo (22.7%),dizziness (22.2%), nausea (21.5%), dysgeusia (20.6%), somnolence(14.9%), headache (13.7%), paranesthesia (11.0%), dissociation (11.0%),feeling abnormal (10.8%), vision blurred (10.3%) and sedation (10.1%).In the safety (OP) analysis set, the most common TEAEs during the OPphase were vertigo (20.0%), dysgeusia (17.4%), somnolence (13.8%),dizziness (13.4%), headache (12.5%) and nausea (10.5%). In the safety(MA) analysis set, the most common TEAEs in esketamine+oral AD duringthe double-blind MA phase were dysgeusia (26.3%), vertigo (25.0%),somnolence (21.1%), dizziness (20.4%), headache (17.8%), nausea (16.4%),vision blurred (15.8%), dissociation (13.8%) and hypoesthesia oral(13.2%). There was no TEAE in ≥10% of subjects with oral AD+placebo inthe safety (MA) analysis set. For the TEP subjects, the most common TEAEwas headache (18.6%) during the OP phase, and viral upper respiratorytract infection (24.1%), headache (22.2%) and dysgeusia (14.8%) duringthe MA phase.

There were no deaths reported in this study.

There were 32 subjects with 39 serious adverse events (SAEs) reported inthis study. A total of 13 subjects experienced serioustreatment-emergent adverse events (TEAEs) during the IND phase in thesafety (IND) analysis set. Three subjects had serious TEAEs consideredas of very likely relationship to intranasal esketamine by theinvestigators: disorientation (Day 1), suicidal ideation (Day 8),sedation (Day 22), and one subject had two serious TEAEs on the same day(Day 5) considered as of very likely relationship to intranasalesketamine: autonomic nervous system imbalance and simple partialseizures. One subject had a serious TEAE considered by the investigatoras probably related to intranasal esketamine: lacunar stroke (Day 1).One subject had a serious TEAE considered possibly related to intranasalesketamine: hypothermia (Day 10). Eleven subjects experienced serioustreatment-emergent adverse events during the OP phase in the safety (OP)analysis set. No serious TEAEs were considered to be possibly, probablyor very likely related to esketamine. Five subjects (4 inesketamine+oral AD, 1 in oral AD+placebo) in the safety (MA) analysisset experienced serious treatment-emergent adverse events during the MAphase. All the events were considered as not related to intranasalmedication or oral AD. Two subjects had serious AEs considered notrelated to oral AD in the follow-up phase. One subject experienced twoserious AEs considered to be possibly related to oral AD. No TEP subjectexperienced a serious treatment-emergent adverse event during the OPphase. One TEP subject experienced a serious TEAE during the MA phasewhich was considered not related to intranasal medication or oral AD.

There were 22 subjects who discontinued the IND phase intranasal studymedication due to treatment-emergent adverse events in the safety (IND)analysis set and 5 subjects who discontinued the OP phase intranasalstudy medication due to treatment-emergent adverse events in the safety(OP) analysis set. Per study design, these subjects could continue theoral AD in the follow-up phase if appropriate. Eight subjectsdiscontinued the IND phase oral AD medication and 2 subjectsdiscontinued the OP phase oral AD medication due to treatment-emergentadverse events. There were 7 subjects (4 subjects in esketamine+oral AD,3 subjects in oral AD+placebo) who discontinued the MA phase intranasalstudy medication due to treatment-emergent adverse events in the safety(MA) analysis set. Per study design, these subjects could continue theoral AD in the follow-up phase if appropriate. Three subjects inesketamine+oral AD arm discontinued the MA phase oral AD studymedication due to treatment-emergent adverse events; no subjects in oralAD+ intranasal placebo arm discontinued the MA phase oral AD studymedication due to treatment-emergent adverse events. No TEP subjectsdiscontinued the OP phase intranasal study medication or oral AD due totreatment-emergent adverse events in the safety (OP_TEP) analysis set.There were 2 TEP subjects who discontinued the MA phase intranasal studymedication in the safety (MA_TEP) analysis set. One of these subjectsdiscontinued the MA phase due to both intranasal and oral ADmedications.

Other Safety Observations

Transient blood pressure increases for the esketamine+oral AD grouppeaked at 40 minutes post dose and returned closer to predose levels by1.5 hours post dose.

Dissociative/perceptual change symptoms measured by the CADSS, suggestonset of these symptoms occurred shortly after the start of theintranasal dosing session and resolved by 1.5 hours post dose.

The proportion of subjects with sedation (as measured by the MOAA/Sscale ≤3) was ≤3.9% for esketamine+oral AD for each dosing day in allphases.

Subject and Treatment Information

A total of 1097 subjects were enrolled across 164 sites in 16 countries(Belgium, Brazil, Canada, Czech Republic, Estonia, France, Germany,Hungary, Italy, Mexico, Poland, Slovakia, Spain, Sweden, Turkey, andUnited States). Excluding 378 screen failures and 14 subjects from sitePL10002 due to GCP issues, 705 subjects with a DSM-5 (Diagnostic andStatistical Manual of Mental Disorders, 5th Edition) diagnosis of MDDwere enrolled.

Four hundred thirty-seven subjects were directly enrolled into the 3003study, 150 subjects were transferred from the ESKETINTRD3001 study, and118 subjects were transferred from the ESKETINTRD3002 study. Results arepresented in Table 73.

TABLE 73 Number of Direct-entry and Transferred-entry Subjects Enrolledin Study (Study ESKETINTRD3003: All Enrolled Analysis Set) Total (N =705) Direct-entry subjects in study ESKETINTRD3003 437 (62.0%)Transferred-entry subjects from: Study ESKETINTRD3001 150 (21.3%)Transfer-entry Placebo 38 (5.4%) Transfer-entry Esketamine 112 (15.9%)Study ESKETINTRD3002 118 (16.7%) Transfer-entry Placebo 48 (6.8%)Transfer-entry Esketamine 70 (9.9%)

TABLE 74 Number of Subjects in Each Phase and Analysis Set (StudyESKETINTRD3003: All Enrolled Analysis Set) Intranasal Esk + Oral AD +Oral AD Intranasal Placebo Total Open-label induction phase Full (IND)430 N/A 430 Safety (IND) 437 N/A 437 Optimization phase Full (OP) 452 0452 Safety (OP) 455 0 455 Safety transfer-entry 0 86 86 placebo (OP)^(a) Maintenance phase Interim full (stable 49 47 96 remitters) ^(b)Full (stable remitters) 90 86 176 Full (stable responders) 62 59 121Safety (MA) 152 145 297 Safety (stable remitters) 90 86 176 Safetytransfer-entry 0 54 54 placebo (MA) ^(a) Follow-up phase Follow-up 48164 545 ^(a) Transferred entry subjects who continued to receive an oralantidepressant plus intranasal Placebo. ^(b) Full (Stable Remitters)analysis set at the time of Interim analysis. Stable Remission: MADRStotal score ≤12 for at least 3 of the last 4 weeks of the optimizationphase, but one excursion of a MADRS total score >12 or one missing MADRSassessment is permitted at Optimization week 13 or 14 only. The MADRStotal score at weeks 15 and 16 must be ≤12. Stable Response: ≥50%reduction in the MADRS total score from baseline (Day 1 of inductionphase; pre-randomization/prior to the first intranasal dose) in each ofthe last 2 weeks of the optimization phase, but does not meet criteriafor stable remission. For transferred-entry subjects, Day 1 of theopen-label induction phase will take place in studies ESKETINTRD3001 orESKETINTRD3002.

Study Completion/Withdrawal Information

Of the 437 safety (IND) analysis set subjects (direct-entry subjectsonly), 273 (62.5%) subjects completed the 28-day IND phase and 164(37.5%) withdrew. Results are presented in Table 75. The majority ofsubjects were discontinued from the IND phase due to subject ‘did notmeet criteria for continuing into the next phase’ (114 subjects).

TABLE 75 Study Completion/Withdrawal Information; Open-label InductionPhase (Study ESKETINTRD3003: Safety (IND) Analysis Set) Intranasal Esk +Oral AD (N = 437) Continued to optimization phase 273 (62.5%) Withdrawnduring open-label induction phase 164 (37.5%) Adverse event 22 (5.0%)Lack of efficacy 2 (0.5%) Lost to follow-up 1 (0.2%) Protocol violation2 (0.5%) Subject does not meet criteria for continuing 114 (26.1%) intothe next phase Withdrawal by subject 15 (3.4%) Other 8 (1.8%)

Of the 455 subjects entering the OP phase (including 182esketamine-treated transferred-entry subjects from the TRD3001 orTRD3002 study) in the safety (OP) analysis set, 297 (65.3%) subjectscompleted the 12-week OP phase and 158 (34.7%) subjects withdrew.Results are presented in Table 76.

TABLE 76 Study Completion/Withdrawal Information; Optimization Phase(Study ESKETINTRD3003: Safety (OP) Analysis Set) Intranasal Esk + OralAD (N = 455) Continued to maintenance phase 297 (65.3%) Withdrawn duringoptimization phase 158 (34.7%) Adverse event 5 (1.1%) Lack of efficacy 8(1.8%) Lost to follow-up 2 (0.4%) MADRS total score ≥22 for 2consecutive 14 (3.1%) visit ^(a) Protocol violation 4 (0.9%) Subjectdoes not meet criteria for continuing 107 (23.5%) into the next phaseSubject does not meet criteria for stable 106 (23.3%) remission orstable response Subject missed ≥3 MADRS assessments ^(b) 1 (0.2%)Withdrawal by subject 8 (1.8%) Other 10 (2.2%) ^(a) This criterionapplies to subjects prior to Protocol Amendment 3. ^(b) This criterionapplies to subjects prior to Protocol Amendment 4.

The most frequent reasons for discontinuation were due to subject ‘didnot meet criteria for continuing into the next phase’ (107 subjects).Note that the safety (OP) and safety (MA) analysis sets do not includethe transferred-entry subjects who continued to receive oral AD+placebo(TEP) during the subsequent phases, see Tables 77 and 78 for StudyCompletion/Withdrawal Information for these analysis sets.

TABLE 77 Study Completion/Withdrawal Information; Optimization Phase(Study ESKETINTRD3003: Safety (OP_TEP) Analysis Set) Oral AD +Intranasal Placebo (N = 86) Continued to maintenance phase 54 (62.8%)Withdrawn during optimization phase 32 (37.2%) Lost to follow-up 1(1.2%) MADRS total score ≥22 for 2 consecutive 5 (5.8%) visit ^(a)Protocol violation 1 (1.2%) Subject does not meet criteria for 20(23.3%) continuing into the next phase Subject does not meet criteriafor stable 18 (20.9%) remission or stable response Subject missed ≥3MADRS assessments ^(b) 2 (2.3%) Withdrawal by subject 3 (3.5%) Other 2(2.3%) ^(a) This criterion applies to subjects prior to ProtocolAmendment 3. ^(b) This criterion applies to subjects prior to ProtocolAmendment 4.

TABLE 78 Study Completion/Withdrawal Information; Maintenance Phase(Study ESKETINTRD3003: Safety (MA_TEP) Analysis Set) Oral AD +Intranasal Placebo (N = 54) Completed maintenance phase 44 (81.5%)Subjects who relapsed 13 (24.1%) Subjects who remained relapse-free^(a)31 (57.4%) Withdrawn during maintenance phase 10 (18.5%) Adverse event 2(3.7%) Protocol violation 1 (1.9%) Withdrawal by subject 3 (5.6%) Other4 (7.4%) ^(a)Subjects were considered completers if they wererelapse-free at the time of the study termination

Of the 176 subjects in the full (stable remitters) analysis set, 159(90.3%) subjects completed the MA phase (of those, 63 (35.8%) had arelapse event and 96 (54.5%) remained relapse-free at the time of thestudy termination). Results are presented in Table 79. The most frequentreason for withdrawal was ‘other’ (8 subjects).

TABLE 79 Study Completion/Withdrawal Information; Maintenance Phase(Study ESKETINTRD3003: Full (Stable Remitters) Analysis Set) IntranasalEsk + Oral AD + Oral AD Intranasal Placebo Total (N = 90) (N = 86) (N =176) Completed maintenance phase 82 (91.1%) 77 (89.5%) 159 (90.3%)Subjects who relapsed 24 (26.7%) 39 (45.3%) 63 (35.8%) Subjects whoremained relapse-free ^(a) 58 (64.4%) 38 (44.2%) 96 (54.5%) Withdrawnduring maintenance phase 8 (8.9%) 9 (10.5%) 17 (9.7%) Adverse event 1(1.1%) 1 (1.2%) 2 (1.1%) Pregnancy 1 (1.1%) 0 1 (0.6%) Withdrawal bysubject 3 (3.3%) 3 (3.5%) 6 (3.4%) Other 3 (3.3%) 5 (5.8%) 8 (4.5%) ^(a)Subjects were considered completers if they were relapse-free at thetime of the study termination

Of the 121 subjects in the full (stable responders) analysis set, 113(93.4%) subjects completed the MA phase (of those, 50 (41.3%) had arelapse event and 63 (52.1%) remained relapse-free at the time of thestudy termination). Results are presented in Table 80. The most frequentreason for withdrawal was ‘withdrawal by subject’ (3 subjects).

TABLE 80 Study Completion/Withdrawal Information; Maintenance Phase(Study ESKETINTRD3003: Full (Stable Responders) Analysis Set) IntranasalEsk + Oral AD + Oral AD Intranasal Placebo Total (N = 62) (N = 59) (N =121) Completed maintenance phase 57 (91.9%) 56 (94.9%) 113 (93.4%)Subjects who relapsed 16 (25.8%) 34 (57.6%) 50 (41.3%) Subjects whoremained relapse-free ^(a) 41 (66.1%) 22 (37.3%) 63 (52.1%) Withdrawnduring maintenance phase 5 (8.1%) 3 (5.1%) 8 (6.6%) Adverse event 0 1(1.7%) 1 (0.8%) Lost to follow-up 1 (1.6%) 0 1 (0.8%) Noncompliance withstudy drug 0 1 (1.7%) 1 (0.8%) Protocol violation 1 (1.6%) 0 1 (0.8%)Withdrawal by subject 2 (3.2%) 1 (1.7%) 3 (2.5%) Other 1 (1.6%) 0 1(0.8%) ^(a) Subjects were considered completers if they wererelapse-free at the time of the study termination

Subjects could enter the follow-up phase from the IND phase, OP phase orMA phase. A total of 545 subjects entered the follow-up phase and 532(97.6%) completed the follow-up phase.

Demographic and Baseline Characteristics

Demographic and baseline characteristics are displayed in Table 81 forthe all enrolled analysis set. The majority of subjects enrolled werefemale (64.8%).

TABLE 81 Demographic and Baseline (IND) Characteristics (StudyESKETINTRD3003: All Enrolled Analysis Set) Total (N = 705) Age (years) N705 Mean (SD) 46.1 (11.10) Median 47.0 Range (18; 64) Age category(years), n (%) N 705 18-44 292 (41.4%) 45-64 413 (58.6%) Sex, n (%) N705 Male 248 (35.2%) Female 457 (64.8%) Race, n (%) N 705 AmericanIndian or Alaskan native 1 (0.1%) Asian 3 (0.4%) Black or AfricanAmerican 31 (4.4%) White 635 (90.1%) Other 22 (3.1%) Multiple 4 (0.6%)Not Reported 9 (1.3%) Ethnicity, n (%) N 705 Hispanic or Latino 94(13.3%) Not Hispanic or Latino 600 (85.1%) Not Reported 10 (1.4%)Unknown 1 (0.1%) Baseline weight (kg) N 705 Mean (SD) 81.61 (19.408)Median 80.00 Range  (44.1; 179.0) Baseline height (cm) N 705 Mean (SD)168.88 (10.185) Median 168.00 Range (136.0; 210.3) Baseline body massindex (kg/m²) N 705 Mean (SD) 28.6 (6.23) Median 27.6 Range (17; 67) BMIcategory (kg/m²), n (%) N 705 Underweight <18.5 6 (0.9%) Normal 18.5-<25195 (27.7%) Overweight 25-<30 259 (36.7%) Obese 30-<40 212 (30.1%)Morbidly obese ≥40 33 (4.7%) Employment status, n (%) ^(a) N 705 Anytype of employment 448 (63.5%) Any type of unemployment 180 (25.5%)Other 77 (10.9%) Hypertension status, n (%) ^(b) N 705 Yes 147 (20.9%)No 558 (79.1%) Country, n (%) N 705 Belgium 14 (2.0%) Brazil 64 (9.1%)Canada 5 (0.7%) Czech Republic 99 (14.0%) Estonia 1 (0.1%) France 10(1.4%) Germany 7 (1.0%) Hungary 35 (5.0%) Italy 21 (3.0%) Mexico 35(5.0%) Poland 132 (18.7%) Slovakia 7 (1.0%) Spain 16 (2.3%) Sweden 16(2.3%) Turkey 53 (7.5%) United States 190 (27.0%) Region, n (%) N 705Europe 411 (58.3%) North America 195 (27.7%) Other 99 (14.0%) Class oforal antidepressant, n (%) N 699 SNR 440 (62.9%) SSRI 259 (37.1%) Oralantidepressant, n (%) N 699 Duloxetine 323 (46.2%) Escitalopram 128(18.3%) Sertraline 130 (18.6%) Venlafaxine extended release (XR) 118(16.9%) ^(a) Any type of employment includes: any category containing“Employed”, Sheltered Work, Housewife or Dependent Husband, and Student;any type of unemployment includes: any category containing “Unemployed”;Other includes: Retired and No Information Available. ^(b) Hypertensionstatus is classified as Yes if hypertension is recorded in medicalhistory.

The mean (SD) age was 46.1 (11.10) years, ranging from 18 to 64 years.Baseline psychiatric history for the all enrolled analysis set ispresented in Table 82. The mean (SD) baseline (IND) MADRS total scorewas 37.9 (5.50), ranging from 4 to 53.

TABLE 82 Baseline (IND) Psychiatric History (Study ESKETINTRD3003: AllEnrolled Analysis Set) Total (N = 705) Age when diagnosed with MDD(years) N 705 Mean (SD) 32.7 (11.70) Median 32.0 Range (5; 64) BaselineMADRS total score N 705 Mean (SD) 37.9 (5.50) Median 38.0 Range (4; 53)Screening IDS-C30 total score N 705 Mean (SD) 47.2 (7.26) Median 47.0Range (34; 76)  Baseline CGI-S N 705 Mean (SD) 5.1 (0.66) Median 5.0Range (3; 7)  Baseline CGI-S category, n (%) N 705 Normal, not at allill 0 Borderline mentally ill 0 Mildly ill 2 (0.3%) Moderately ill 98(13.9%) Markedly ill 412 (58.4%) Severely ill 187 (26.5%) Among the mostextremely ill patients 6 (0.9%) Baseline PHQ-9 total score N 705 Mean(SD) 19.9 (4.18) Median 20.0 Range (3; 27) Screening C-SSRS lifetime^(a), n (%) N 705 No event 407 (57.7%) Suicidal ideation 193 (27.4%)Suicidal behavior 105 (14.9%) Screening C-SSRS past 6 or 12 months ^(a),n (%) N 705 No event 499 (70.8%) Suicidal ideation (past 6 months) 205(29.1%) Suicidal behavior (past 12 months) 1 (0.1%) Duration of currentepisode (wks) N 705 Mean (SD) 132.2 (209.18) Median 64.0 Range  (4;2288) Previous antidepressant medications ^(b), n (%) N 702 1 77 (11.0%)2 394 (56.1%) 3 150 (21.4%) 4 59 (8.4%) 5 20 (2.8%) 8 1 (0.1%) 9 1(0.1%) Family history of depression, n (%) N 705 Yes 318 (45.1%) No 387(54.9%) Family history of anxiety disorder, n (%) N 705 Yes 64 (9.1%) No641 (90.9%) Family history of bipolar disorder, n (%) N 705 Yes 46(6.5%) No 659 (93.5%) Family history of schizophrenia, n (%) N 705 Yes28 (4.0%) No 677 (96.0%) Family history of alcohol abuse, n (%) N 705Yes 95 (13.5%) No 610 (86.5%) Family history of substance abuse, n (%) N705 Yes 29 (4.1%) No 676 (95.9%) ^(a) C-SSRS category: No event = 0;Suicidal ideation = 1, 2, 3, 4, 5; Suicidal behavior = 6, 7, 8, 9, 10^(b) Number of antidepressant medications with non-response (defined as≤25% improvement) taken for at least 6 weeks during the current episodeas obtained from MGH-ATRQ at the time of first screening visit.

Demographic and baseline characteristics, and baseline psychiatrichistory for the safety (IND) analysis set are displayed in the Tables 83and 84. The majority of subjects enrolled were female (61.3%). The mean(SD) age was 46.5 (10.96) years, ranging from 19 to 64 years. The mean(SD) baseline (IND) MADRS total score was 37.8 (5.51), ranging from 4 to53.

TABLE 83 Demographic and Baseline (IND) Characteristics (StudyESKETINTRD3003: Safety (IND) Analysis Set) Total (N = 437) Age (years) N437 Mean (SD) 46.5 (10.96) Median 48.0 Range (19; 64) Age category(years), n (%) N 437 18-44 173 (39.6%) 45-64 264 (60.4%) Sex, n (%) N437 Male 169 (38.7%) Female 268 (61.3%) Race, n (%) N 437 Asian 1 (0.2%)Black or African American 18 (4.1%) White 413 (94.5%) Other 1 (0.2%)Multiple 4 (0.9%) Ethnicity, n (%) N 437 Hispanic or Latino 31 (7.1%)Not Hispanic or Latino 406 (92.9%) Baseline weight (kg) N 437 Mean (SD)81.53 (19.305) Median 80.00 Range  (47.2; 179.0) Baseline height (cm) N437 Mean (SD) 169.22 (10.016) Median 168.20 Range (136.0; 210.3)Baseline body mass index (kg/m²) N 437 Mean (SD) 28.5 (6.35) Median 27.4Range (18; 67) BMI category (kg/m²), n (%) N 437 Underweight <18.5 4(0.9%) Normal 18.5-<25 128 (29.3%) Overweight 25-<30 159 (36.4%) Obese30-<40 124 (28.4%) Morbidly obese ≥40 22 (5.0%) Employment status, n (%)^(a) N 437 Any type of employment 280 (64.1%) Any type of unemployment109 (24.9%) Other 48 (11.0%) Hypertension status, n (%) ^(b) N 437 Yes94 (21.5%) No 343 (78.5%) Country, n (%) N 437 Brazil 28 (6.4%) CzechRepublic 59 (13.5%) Hungary 33 (7.6%) Italy 21 (4.8%) Poland 106 (24.3%)Spain 10 (2.3%) Sweden 16 (3.7%) Turkey 53 (12.1%) United States 111(25.4%) Region, n (%) N 437 Europe 298 (68.2%) North America 111 (25.4%)Other 28 (6.4%) Class of oral antidepressant, n (%) N 431 SNRI 266(61.7%) SSRI 165 (38.3%) Oral antidepressant, n (%) N 431 Duloxetine 195(45.2%) Escitalopram 76 (17.6%) Sertraline 89 (20.6%) Venlafaxineextended release (XR) 71 (16.5%) ^(a) Any type of employment includes:any category containing “Employed”, Sheltered Work, Housewife orDependent Husband, and Student; any type of unemployment includes: anycategory containing “Unemployed”; Other includes: Retired and NoInformation Available. ^(b) Hypertension status is classified as Yes ifhypertension is recorded in medical history.

TABLE 84 Baseline (IND) Psychiatric History (Study ESKETINTRD3003:Safety (IND) Analysis Set) Total (N = 437) Age when diagnosed with MDD(years) N 437 Mean (SD) 32.3 (11.35) Median 31.0 Range (5; 61) BaselineMADRS total score N 437 Mean (SD) 37.8 (5.51) Median 38.0 Range (4; 53)Screening IDS-C30 total score N 437 Mean (SD) 47.4 (7.36) Median 47.0Range (34; 76)  Baseline CGI-S N 437 Mean (SD) 5.2 (0.65) Median 5.0Range (3; 7)  Baseline CGI-S category, n (%) N 437 Normal, not at allill 0 Borderline mentally ill 0 Mildly ill 2 (0.5%) Moderately ill 54(12.4%) Markedly ill 258 (59.0%) Severely ill 119 (27.2%) Among the mostextremely ill patients 4 (0.9%) Baseline PHQ-9 total score N 437 Mean(SD) 19.6 (4.32) Median 20.0 Range (3; 27) Screening C-SSRS lifetime^(a), n (%) N 437 No event 252 (57.7%) Suicidal ideation 118 (27.0%)Suicidal behavior 67 (15.3%) Screening C-SSRS past 6 or 12 months ^(a),n (%) N 437 No event 320 (73.2%) Suicidal ideation (past 6 months) 117(26.8%) Suicidal behavior (past 12 months) 0 Duration of current episode(wks) N 437 Mean (SD) 117.3 (186.94) Median 59.0 Range  (4; 1560)Previous antidepressant medications ^(b), n (%) N 436 1 46 (10.6%) 2 243(55.7%) 3 92 (21.1%) 4 39 (8.9%) 5 15 (3.4%) 8 1 (0.2%) Family historyof depression, n (%) N 437 Yes 174 (39.8%) No 263 (60.2%) Family historyof anxiety disorder, n (%) N 437 Yes 40 (9.2%) No 397 (90.8%) Familyhistory of bipolar disorder, n (%) N 437 Yes 24 (5.5%) No 413 (94.5%)Family history of schizophrenia, n (%) N 437 Yes 17 (3.9%) No 420(96.1%) Family history of alcohol abuse, n (%) N 437 Yes 58 (13.3%) No379 (86.7%) Family history of substance abuse, n (%) N 437 Yes 14 (3.2%)No 423 (96.8%) ^(a) C-SSRS category: No event = 0; Suicidal ideation =1, 2, 3, 4, 5; Suicidal behavior = 6, 7, 8, 9, 10 ^(b) Number ofantidepressant medications with non-response (defined as ≤25%improvement) taken for at least 6 weeks during the current episode asobtained from MGH-ATRQ at the time of first screening visit.

Demographic and baseline characteristics, and baseline psychiatrichistory for the full (stable remitters) analysis set are displayed inthe Tables 85 and 86. The majority of the stable remitters randomized tothe MA phase were female (66.5%). The mean (SD) age was 45.8 (11.64)years, ranging from 19 to 64 years. The mean (SD) baseline (IND) MADRStotal score was 37.5 (4.93), ranging from 26 to 49.

TABLE 85 Demographic and Baseline (IND) Characteristics (StudyESKETINTRD3003: Full (Stable Remitters) Analysis Set) Oral AD +Intranasal Esk + Intranasal Placebo Total Oral AD (N = 90) (N = 86) (N =176) Age (years) N 90 86 176 Mean (SD) 45.4 (12.12) 46.2 (11.16) 45.8(11.64) Median 47.5 45.0 46.5 Range (19; 64) (19; 64) (19; 64) Agecategory (years), n (%) N 90 86 176 18-44 38 (42.2%) 37 (43.0%) 75(42.6%) 45-64 52 (57.8%) 49 (57.0%) 101 (57.4%) Sex, n (%) N 90 86 176Male 32 (35.6%) 27 (31.4%) 59 (33.5%) Female 58 (64.4%) 59 (68.6%) 117(66.5%) Race, n (%) N 90 86 176 Black or African American 4 (4.4%) 6(7.0%) 10 (5.7%) White 80 (88.9%) 76 (88.4%) 156 (88.6%) American Indianor Alaskan native 0 1 (1.2%) 1 (0.6%) Other 2 (2.2%) 1 (1.2%) 3 (1.7%)Multiple 1 (1.1%) 0 1 (0.6%) Not Reported 3 (3.3%) 2 (2.3%) 5 (2.8%)Ethnicity, n (%) N 90 86 176 Hispanic or Latino 14 (15.6%) 12 (14.0%) 26(14.8%) Not Hispanic or Latino 73 (81.1%) 72 (83.7%) 145 (82.4%) NotReported 3 (3.3%) 2 (2.3%) 5 (2.8%) Baseline weight (kg) N 90 86 176Mean (SD) 82.78 (19.554) 84.21 (20.781) 83.48 (20.118) Median 82.0581.05 82.00 Range  (47.0; 147.0)  (44.1; 179.0)  (44.1; 179.0) Baselineheight (cm) N 90 86 176 Mean (SD) 169.05 (11.330) 168.60 (9.673) 168.83(10.525) Median 167.55 166.00 167.00 Range (150.0; 210.3) (150.0; 192.0)(150.0; 210.3) Baseline body mass index (kg/m²) N 90 86 176 Mean (SD)28.9 (5.75) 29.5 (6.26) 29.2 (6.00) Median 28.4 28.70 28.6 Range (18;47) (20; 54) (18; 54) BMI category (kg/m²), n (%) N 90 86 176Underweight <18.5 2 (2.2%) 0 2 (1.1%) Normal 18.5-<25 19 (21.1%) 18(20.9%) 37 (21.0%) Overweight 25-<30 32 (35.6%) 33 (38.4%) 65 (36.9%)Obese 30-<40 33 (36.7%) 30 (34.9%) 63 (35.8%) Morbidly obese ≥40 4(4.4%) 5 (5.8%) 9 (5.1%) Employment status, n (%) ^(a) N 90 86 176 Anytype of employment 57 (63.3%) 54 (62.8%) 111 (63.1%) Any type ofunemployment 23 (25.6%) 19 (22.1%) 42 (23.9%) Other 10 (11.1%) 13(15.1%) 23 (13.1%) Hypertension status, n (%) ^(b) N 90 86 176 Yes 23(25.6%) 19 (22.1%) 42 (23.9%) No 67 (74.4%) 67 (77.9%) 134 (76.1%)Country, n (%) N 90 86 176 Belgium 1 (1.1%) 1 (1.2%) 2 (1.1%) Brazil 11(12.2%) 11 (12.8%) 22 (12.5%) Canada 1 (1.1%) 0 1 (0.6%) Czech Republic14 (15.6%) 14 (16.3%) 28 (15.9%) France 3 (3.3%) 3 (3.5%) 6 (3.4%)Germany 0 1 (1.2%) 1 (0.6%) Hungary 2 (2.2%) 2 (2.3%) 4 (2.3%) Italy 2(2.2%) 1 (1.2%) 3 (1.7%) Mexico 5 (5.6%) 5 (5.8%) 10 (5.7%) Poland 19(21.1%) 18 (20.9%) 37 (21.0%) Slovakia 2 (2.2%) 1 (1.2%) 3 (1.7%) Spain2 (2.2%) 3 (3.5%) 5 (2.8%) Sweden 3 (3.3%) 3 (3.5%) 6 (3.4%) Turkey 4(4.4%) 3 (3.5%) 7 (4.0%) United States 21 (23.3%) 20 (23.3%) 41 (23.3%)Region, n (%) N 90 86 176 Europe 52 (57.8%) 50 (58.1%) 102 (58.0%) NorthAmerica 22 (24.4%) 20 (23.3%) 42 (23.9%) Other 16 (17.8%) 16 (18.6%) 32(18.2%) Class of oral antidepressant, n (%) N 90 86 176 SNRI 62 (68.9%)58 (67.4%) 120 (68.2%) SSRI 28 (31.1%) 28 (32.6%) 56 (31.8%) Oralantidepressant, n (%) N 90 86 176 Duloxetine 47 (52.2%) 38 (44.2%) 85(48.3%) Escitalopram 13 (14.4%) 14 (16.3%) 27 (15.3%) Sertraline 15(16.7%) 14 (16.3%) 29 (16.5%) Venlafaxine extended release (XR) 15(16.7%) 20 (23.3%) 35 (19.9%) ^(a) Any type of employment includes: anycategory containing “Employed”, Sheltered Work, Housewife or DependentHusband, and Student; any type of unemployment includes: any categorycontaining “Unemployed”; Other includes: Retired and No InformationAvailable. ^(b) Hypertension status is classified as Yes if hypertensionis recorded in medical history.

TABLE 86 Baseline (IND) Psychiatric History (Study ESKETINTRD3003: Full(Stable Remitters) Analysis Set) Oral AD + Intranasal Esk + IntranasalPlacebo Total Oral AD (N = 90) (N = 86) (N = 176) Age when diagnosedwith MDD (years) N 90 86 176 Mean (SD) 32.5 (11.42) 33.4 (11.41) 32.9(11.39) Median 33.0 32.0 32.5 Range  (5; 55) (10; 60)  (5; 60) BaselineMADRS total score N 90 86 176 Mean (SD) 37.4 (5.20) 37.6 (4.66) 37.5(4.93) Median 37.0 37.5 37.0 Range (26; 49) (28; 47) (26; 49) ScreeningIDS-C30 total score N 90 86 176 Mean (SD) 46.9 (6.24) 47.7 (7.77) 47.3(7.02) Median 46.0 48.0 47.0 Range (36; 64) (34; 73) (34; 73) BaselineCGI-S N 90 86 176 Mean (SD) 5.1 (0.69) 5.1 (0.71) 5.1 (0.70) Median 5.05.0 5.0 Range (4; 6) (3; 7) (3; 7) Baseline CGI-S category, n (%) N 9086 176 Normal, not at all ill 0 0 0 Borderline mentally ill 0 0 0 Mildlyill 0 1 (1.2%) 1 (0.6%) Moderately ill 18 (20.0%) 13 (15.1%) 31 (17.6%)Markedly ill 47 (52.2%) 51 (59.3%) 98 (55.7%) Severely ill 25 (27.8%) 19(22.1%) 44 (25.0%) Among the most extremely ill patients 0 2 (2.3%) 2(1.1%) Baseline PHQ-9 total score N 90 86 176 Mean (SD) 19.2 (4.16) 19.8(3.43) 19.5 (3.82) Median 19.0 20.0 20.0 Range  (5; 27) (10; 27)  (5;27) Screening C-SSRS lifetime ^(a), n (%) N 90 86 176 No event 64(71.1%) 62 (72.1%) 126 (71.6%) Suicidal ideation 19 (21.1%) 17 (19.8%)36 (20.5%) Suicidal behavior 7 (7.8%) 7 (8.1%) 14 (8.0%) ScreeningC-SSRS past 6 or 12 months ^(a), n (%) N 90 86 176 No event 72 (80.0%)72 (83.7%) 144 (81.8%) Suicidal ideation (past 6 months) 18 (20.0%) 14(16.3%) 32 (18.2%) Suicidal behavior (past 12 months) 0 0 0 Duration ofcurrent episode (wks) N 90 86 176 Mean (SD) 112.2 (171.30) 110.5(147.41) 111.4 (159.62) Median 51.5 58.0 54.0 Range  (12; 1040)  (9;884)   (9; 1040) Previous antidepressant medications ^(b), n (%) N 90 84174 1 10 (11.1%) 10 (11.9%) 20 (11.5%) 2 61 (67.8%) 52 (61.9%) 113(64.9%) 3 11 (12.2%) 15 (17.9%) 26 (14.9%) 4 6 (6.7%) 7 (8.3%) 13 (7.5%)5 2 (2.2%) 0 2 (1.1%) Family history of depression, n (%) N 90 86 176Yes 39 (43.3%) 36 (41.9%) 75 (42.6%) No 51 (56.7%) 50 (58.1%) 101(57.4%) Family history of anxiety disorder, n (%) N 90 86 176 Yes 5(5.6%) 4 (4.7%) 9 (5.1%) No 85 (94.4%) 82 (95.3%) 167 (94.9%) Familyhistory of bipolar disorder, n (%) N 90 86 176 Yes 7 (7.8%) 5 (5.8%) 12(6.8%) No 83 (92.2%) 81 (94.2%) 164 (93.2%) Family history ofschizophrenia, n (%) N 90 86 176 Yes 4 (4.4%) 1 (1.2%) 5 (2.8%) No 86(95.6%) 85 (98.8%) 171 (97.2%) Family history of alcohol abuse, n (%) N90 86 176 Yes 7 (7.8%) 9 (10.5%) 16 (9.1%) No 83 (92.2%) 77 (89.5%) 160(90.9%) Family history of substance abuse, n (%) N 90 86 176 Yes 2(2.2%) 6 (7.0%) 8 (4.5%) No 88 (97.8%) 80 (93.0%) 168 (95.5%) ^(a)C-SSRS category: No event = 0; Suicidal ideation = 1, 2, 3, 4, 5;Suicidal behavior = 6, 7, 8, 9, 10 ^(b) Number of antidepressantmedications with non-response (defined as ≤25% improvement) taken for atleast 6 weeks during the current episode as obtained from MGH-ATRQ atthe time of first screening visit.

Extent of Exposure

The extent of exposure to intranasal study medication during the MAphase for the full (stable remitters) analysis set and full (stableresponders) analysis set are displayed in Tables 87 and 88.

TABLE 87 Extent of Exposure to Intranasal Study Medication; MaintenancePhase (Study ESKETINTRD3003: Full (Stable Remitters) Analysis Set)Intranasal Esk + Oral AD Oral AD + Intranasal Placebo Total CumulativeTotal Cumulative Duration Duration Duration Duration (N = 90) (N = 90)(N = 86) (N = 86) Duration, weeks N 90 90 86 86 Category, n (%) ≤Week 4(≤28 days) 7 (7.8%) 7 (7.8%) 23 (26.7%) 23 (26.7%) Week 4-8 (Days 29-56)10 (11.1%) 17 (18.9%) 12 (14.0%) 35 (40.7%) Week 8-12 (Days 57-84) 15(16.7%) 32 (35.6%) 10 (11.6%) 45 (52.3%) Week 12-16 (Days 85-112) 7(7.8%) 39 (43.3%) 8 (9.3%) 53 (61.6%) Week 16-20 (Days 113-140) 12(13.3%) 51 (56.7%) 7 (8.1%) 60 (69.8%) Week 20-24 (Days 141-168) 9(10.0%) 60 (66.7%) 4 (4.7%) 64 (74.4%) Week 24-28 (Days 169-196) 7(7.8%) 67 (74.4%) 4 (4.7%) 68 (79.1%) Week 28-32 (Days 197-224) 4 (4.4%)71 (78.9%) 7 (8.1%) 75 (87.2%) Week 32-36 (Days 225-252) 5 (5.6%) 76(84.4%) 2 (2.3%) 77 (89.5%) Week 36-40 (Days 253-280) 4 (4.4%) 80(88.9%) 2 (2.3%) 79 (91.9%) Week 40-44 (Days 281-308) 2 (2.2%) 82(91.1%) 3 (3.5%) 82 (95.3%) Week 44-48 (Days 309-336) 1 (1.1%) 83(92.2%) 1 (1.2%) 83 (96.5%) >Week 48 (>Day 336) 7 (7.8%) 90 (100.0%) 3(3.5%) 86 (100.0%) Mean (SD) 21.1 (16.25) 16.0 (16.12) Median 17.7 10.2Range (0; 83) (0; 76) The duration of exposure is defined as theduration between the date of the first exposure and the last date ofexposure to intranasal study medication in the Maintenance Phase. Itincludes days on which subjects did not actually take intranasal studymedication.

TABLE 88 Extent of Exposure to Intranasal Study Medication; MaintenancePhase (Study ESKETINTRD3003: Full (Stable Responders) Analysis Set)Intranasal Esk + Oral AD Oral AD + Intranasal Placebo Total CumulativeTotal Cumulative Duration Duration Duration Duration (N = 62) (N = 62)(N = 59) (N = 59) Duration, weeks N 62 62 59 59 Category, n (%) ≤Week 4(≤28 days) 3 (4.8%) 3 (4.8%) 18 (30.5%) 18 (30.5%) Week 4-8 (Days 29-56)13 (21.0%) 16 (25.8%) 9 (15.3%) 27 (45.8%) Week 8-12 (Days 57-84) 9(14.5%) 25 (40.3%) 8 (13.6%) 35 (59.3%) Week 12-16 (Days 85-112) 4(6.5%) 29 (46.8%) 5 (8.5%) 40 (67.8%) Week 16-20 (Days 113-140) 3 (4.8%)32 (51.6%) 2 (3.4%) 42 (71.2%) Week 20-24 (Days 141-168) 7 (11.3%) 39(62.9%) 5 (8.5%) 47 (79.7%) Week 24-28 (Days 169-196) 4 (6.5%) 43(69.4%) 5 (8.5%) 52 (88.1%) Week 28-32 (Days 197-224) 4 (6.5%) 47(75.8%) 4 (6.8%) 56 (94.9%) Week 32-36 (Days 225-252) 2 (3.2%) 49(79.0%) 1 (1.7%) 57 (96.6%) Week 36-40 (Days 253-280) 2 (3.2%) 51(82.3%) 0 57 (96.6%) Week 40-44 (Days 281-308) 3 (4.8%) 54 (87.1%) 0 57(96.6%) Week 44-48 (Days 309-336) 2 (3.2%) 56 (90.3%) 0 57 (96.6%) >Week48 (>Day 336) 6 (9.7%) 62 (100.0%) 2 (3.4%) 59 (100.0%) Mean (SD) 23.4(20.31) 13.3 (13.53) Median 19.4 10.1 Range (3; 91) (0; 70) The durationof exposure is defined as the duration between the date of the firstexposure and the last date of exposure to intranasal study medication inthe Maintenance Phase. It includes days on which subjects did notactually take intranasal study medication.

On Day 1 of the MA phase, 40/90 (44.4%) of the subjects who receivedintranasal esketamine in the full (stable remitters) analysis set werereceiving the 56 mg dose of esketamine and 50/90 (55.6%) were receivingthe 84 mg dose of esketamine. In the full (stable responders) analysisset, 20/61 (32.8%) of the subjects were receiving the 56 mg dose ofesketamine and 41/61 (67.2%) of the subjects were receiving the 84 mgdose of esketamine. Starting from Week 4 (MA), the intranasal treatmentsession frequency could be adjusted (if applicable) at fixed, 4-weekintervals. Tables 89 and 90 display the dosing regimen subjects were onat least 50% of the time during the MA phase for the full (stableremitters) analysis set and full (stable responders) analysis set. Ofthe 90 randomized stable remitters treated with intranasal esketamineduring the MA phase, 62 (68.9%) subjects used an “every other week”dosing schedule the majority of the time. Of the 62 randomized stableresponders treated with intranasal esketamine during the MA phase, 21(33.9%) subjects used an “every other week” dosing schedule the majorityof the time.

TABLE 89 Frequency of Dosing Frequency (Weekly or Every Other Week) Usedthe Majority of the Time; Maintenance Phase (Study ESKETINTRD3003: Full(Stable Remitters) Analysis Set) Oral AD + Intranasal Esk + IntranasalPlacebo Majority dosing frequency Oral AD (N = 90) (N = 86) Weekly 21(23.3%) 27 (31.4%) Every other week 62 (68.9%) 48 (55.8%) Weekly orevery other week 7 (7.8%) 11 (12.8%) Majority dosing frequency is theregimen subjects were on at least 50% of the time in the MaintenancePhase.

TABLE 90 Frequency of Dosing Frequency (Weekly or Every Other Week) Usedthe Majority of the Time; Maintenance Phase (Study ESKETINTRD3003: Full(Stable Responders) Analysis Set) Oral AD + Intranasal Esk + IntranasalPlacebo Majority dosing frequency Oral AD (N = 62) (N = 59) Weekly 34(54.8%) 36 (61.0%) Every other week 21 (33.9%) 19 (32.2%) Weekly orevery other week  7 (11.3%) 4 (6.8%) Majority dosing frequency is theregimen subjects were on at least 50% of the time in the MaintenancePhase.

Primary Endpoint Analysis

The interim efficacy analysis was performed at a significance level of0.0097 (two-sided). As the study was not stopped for efficacy at theinterim analysis, the final efficacy analysis was performed at asignificance level of 0.046 (two-sided).

The primary efficacy analyses are based on the full (stable remitters)analysis set which is defined as randomized subjects who were in stableremission at the end of the optimization phase and who received at least1 dose of intranasal study drug and 1 dose of oral antidepressant duringthe maintenance phase. One stable responder subject who was incorrectlyrandomized as a stable remitter was included in this analysis set. Theprimary efficacy endpoint is the time from randomization to the firstdocumentation (earliest date) of a relapse during the maintenance phasein esketamine-treated subjects who achieved stable remission at the endof optimization phase.

Relapse is defined as any of the following:

-   -   MADRS total score for 2 consecutive assessments separated by 5        to 15 days. The date of the second MADRS assessment was used for        the date of relapse.    -   Hospitalization for worsening depression or any other clinically        relevant event determined per clinical judgment to be suggestive        of a relapse of depressive illness such as suicide attempt,        completed suicide, or hospitalization for suicide prevention. If        hospitalized for any of these events, the start date of        hospitalization was used for the date of relapse. Otherwise the        date of the event was used if the subject is not hospitalized.    -   In case both relapse criteria are met, the earlier date was        defined as the date of relapse for this subject.

One subject was randomized early (during the Week 12 of the OP phase)but did not start the MA phase until a week later. The time to relapsefor this subject was calculated from the start date of the maintenancephase. The primary efficacy analysis was performed on the full (stableremitters) analysis set, which included 175 stable remitters and 1stable responder (who was incorrectly randomized as a stable remitter)at the end of the optimization phase after treatment with intranasalesketamine plus an oral antidepressant. These subjects received at least1 dose of intranasal study drug and 1 dose of oral antidepressant duringthe maintenance phase. As shown in Table 91 below, results favoredintranasal esketamine+oral AD in delaying relapse compared to oral AD+intranasal placebo. Overall, 24 (26.7%) subjects in the intranasalesketamine+oral AD group and 39 (45.3%) subjects in the oral AD+intranasal placebo group experienced a relapse event during themaintenance phase. Based on the weighted combination test, thedifference between treatment groups was statistically significant(two-sided p=0.003) and was less than 0.046 (the threshold ofstatistical significance). The estimated hazard ratio of intranasalesketamine+oral AD relative to oral AD+ intranasal placebo based onweighted estimates was 0.49 (95% CI: 0.29, 0.84) using R. Thecalculation of the hazard ratio using ADDPLAN was very similar 0.49(0.29; 0.83).

TABLE 91 Time to Relapse and Number (%) of Subjects That RemainedRelapse Free; Maintenance Phase (Study ESKETINTRD3003: Full (StableRemitters) Analysis Set) Intranasal Esk + Oral AD + Time to Relapse(days) ^(a) Oral AD Intranasal Placebo Number assessed 90 86 Numbercensored (%) 66 (73.3%) 47 (54.7%) Number of relapses (%) 24 (26.7%) 39(45.3%) 25% percentile (95% CI) 153.0 (105.0; 225.0) 33.0 (22.0; 48.0)Median (95% CI) NE 273.0 (97.0; NE) 75% percentile (95% CI) NE NE HazardRatio (95% CI) ^(b) 0.49 (0.29; 0.84) Two-sided P-value ^(c) 0.003 ^(a)Based on Kaplan-Meier product limit estimates. ^(b) Hazard ratio and CIare weighted estimates based on Wassmer (2006) and calculated using R.^(c) Two-sided P-value is based on the final test statistic, which is aweighted combination of the log-rank test statistics calculated on theinterim full analysis set and on the full analysis set in stableremitters. NE stands for Not Estimable.

Kaplan-Meier curves of the time to relapse for the two treatment groupsare presented in FIG. 51. The reasons for relapse events for subjectswho experienced a relapse are summarized in Table 92. The most commonreason for relapse was a MADRS total score ≥22 for 2 consecutiveassessments separated by 5 to 15 days.

TABLE 92 Frequency Distribution of Reason for Relapse; Maintenance Phase(Study ESKETINTRD3003: Full (Stable Remitters) Analysis Set) Oral AD +Intranasal Esk + Intranasal Placebo Total Oral AD (N = 90) (N = 86) (N =176) Total number of subjects with relapse 24 39 63 Reason for relapseMADRS total score ≥22 for two consecutive 18 (75.0%) 38 (97.4%) 56(88.9%) assessments ^(a) Completed suicide or hospitalization 6 (25.0%)1 (2.6%) 7 (11.1%) for depression worsening/suicide attempt/suicideprevention or other clinically relevant event AE Preferred TermDepression 4 (16.7%) 1 (2.6%) 5 (7.9%) Depressive symptom 1 (4.2%) 0 1(1.6%) Major depression 1 (4.2%) 0 1 (1.6%) ^(a) Based on twoconsecutive assessments separated by 5 to 15 days.

Subgroup Analyses

A forest plot showing the hazard ratio based on the Cox proportionalhazards model for the preplanned subgroups are shown in FIG. 56. Ingeneral, the results favored esketamine+oral AD treatment groups for thesubgroups.

Sensitivity Analysis

Two sensitivity analyses were performed on the full (stable remitters)analysis set using an unweighted log-rank test and Cox proportionalhazards model with the accumulated 63 events and based on cutoff date ofthe 59^(th) event. Note the sensitivity analysis at the 59^(th) eventwas actually done with 61 relapses as 3 relapses occurred on the sameday as the 59^(th) event. Results are presented in Tables 93 and 94. Theestimated hazard ratio of intranasal esketamine+oral AD relative to oralAD+ intranasal placebo was 0.47 (95% CI: 0.28, 0.78) based on the 63events and 0.46 (0.27, 0.77) based on the 61 events. The results areconsistent with the primary efficacy analysis.

TABLE 93 Cox Regression of Time to Relapse (Days) With Treatment as aFactor; Maintenance Phase (Study ESKETINTRD3003: Full (Stable Remitters)Analysis Set) Intranasal Esk + Oral AD + Time to Relapse (days)^(a) OralAD Intranasal Placebo Number of Assessed 90 86 Number of Censored (%) 66(73.3%) 47 (54.7%) Number of Events (%) 24 (26.7%) 39 (45.3%) 25%percentile (95% CI) 153.0 (105.0; 225.0) 33.0 (22.0; 48.0) Median (95%CI) NE 273.0 (97.0; NE) 75% percentile (95% CI) NE NE Hazard Ratio (95%CI)^(b) 0.47 (0.28; 0.78) Two-sided P-value^(c) 0.003 ^(a)Based onKaplan-Meier product limit estimates. ^(b)Regression analysis ofsurvival data based on Cox proportional hazards model with treatment asa factor. ^(c)Log-rank test. NE stands for Not Estimable.

TABLE 94 Cox Regression of Time to Relapse (Days) With Treatment as aFactor, Using Cut-off Day of 59th Event; Maintenance Phase (StudyESKETINTRD3003: Full (Stable Remitters) Intranasal Esk + Oral AD + Timeto Relapse (days)^(a) Oral AD Intranasal Placebo Number of Assessed 9086 Number of Censored (%) 67 (74.4%) 48 (55.8%) Number of Events (%) 23(25.6%) 38 (44.2%) 25% percentile (95% CI) 153.0 (105.0; 225.0) 33.0(22.0; 48.0) Median (95% CI) NE 273.0 (103.0; NE) 75% percentile (95%CI) NE NE Hazard Ratio (95% CI)^(b) 0.46 (0.27; 0.77) Two-sidedP-value^(c) 0.003 ^(a)Based on Kaplan-Meier product limit estimates.^(b)Regression analysis of survival data based on Cox proportionalhazards model with treatment as a factor ^(c)Log-rank test. NE standsfor Not Estimable.

Other Secondary Efficacy Endpoint Analysis Time to Relapse in StableResponders (but not Remitters)

The time between subject randomization and the first documentation(earliest date) of a relapse in the maintenance phase was comparedbetween treatment groups for subjects in the full (stable responders)analysis set. One subject was randomized early (during the Week 12 ofthe OP phase) but did not start the MA phase until a week later, and onesubject skipped Week 1 of the MA phase. The time to relapse for thesetwo subjects was calculated from the start date of the maintenancephase. As shown in Table 95 below, results favored intranasalesketamine+oral AD in delaying relapse compared to oral AD+ intranasalplacebo. Overall, 16 (25.8%) subjects on intranasal esketamine+oral ADand 34 (57.6%) subjects in the oral AD+ intranasal placebo groupexperienced a relapse event during the maintenance phase. The differencebetween treatment groups was statistically significant (two-sidedp<0.001) using a two-sided log-rank test. The estimated hazard ratio ofintranasal esketamine+oral AD relative to oral AD+ intranasal placebobased on the Cox proportional hazards model with treatment as a factorwas 0.30 (95% CI: 0.16, 0.55). Kaplan-Meier curves of the time torelapse for the two treatment groups are presented in FIG. 52.

The median of time to relapse (95% CI) for the esketamine+oral AD groupwas 635.0 (264.0; 635.0) days; the median of time to relapse (95% CI) inthe oral AD+nasal spray placebo group was 88.0 (46.0; 196.0) days, basedon Kaplan-Meier estimates. As noted, the estimate of the median time torelapse for the esketamine plus oral AD group should be interpreted withcaution as it is heavily influenced by one subject who had a long timeto relapse.

TABLE 95 Time to Relapse and Number (%) of Subjects That RemainedRelapse Free; Maintenance Phase (Study ESKETINTRD3003: Full (StableResponders) Analysis Set) Intranasal Esk + Oral AD + Time to Relapse(days) ^(a) Oral AD Intranasal Placebo Number assessed 62 59 Numbercensored (%) 46 (74.2%) 25 (42.4%) Number of relapses (%) 16 (25.8%) 34(57.6%) 25% percentile (95% CI) 217.0 (56.0; 635.0) 24.0 (17.0; 46.0)Median (95% CI) 635.0 (264.0; 635.0) 88.0 (46.0; 196.0) 75% percentile(95% CI) 635.0 (NE) NE Hazard Ratio (95% CI)^(b) 0.30 (0.16; 0.55)Two-sided P-value^(c) <0.001 ^(a) Based on Kaplan-Meier product limitestimates. ^(b)Regression analysis of survival data based on Coxproportional hazards model with treatment as a factor. ^(c)Log-ranktest. NE stands for Not Estimable.

Safety Summary of All Adverse Events

An overall summary of all treatment-emergent adverse events (TEAEs)during the IND, OP and MA phases for the safety (IND), safety (OP) andsafety (MA) analysis sets (safety (OP) and safety (MA) analysis sets donot include the transferred-entry subjects who continued to receive oralAD+placebo (TEP) during the subsequent phases), are presented in Tables96 to 98. Overall, 76.9% of subjects experienced at least one TEAEduring the IND phase; 73.6% of subjects experienced at least one TEAEduring the OP phase in the safety (OP) analysis set; 82.2% of subjectsin the esketamine+oral AD group and 45.5% of subjects in the oralAD+placebo experienced at least one TEAE during the MA phase in thesafety (MA) analysis set.

TABLE 96 Overall Summary of Treatment-emergent Adverse Events (TEAE);Open-label Induction Phase (Study ESKETINTRD3003: Safety (IND) AnalysisSet) Intranasal Esk + Oral AD (N = 437) TEAE 336 (76.9%) TEAE possiblyrelated to intranasal drug ^(a) 301 (68.9%) TEAE possibly related tooral antidepressant ^(a) 71 (16.2%) TEAE leading to death 0 1 or moreserious TEAE 13 (3.0%) TEAE leading to intranasal drug withdrawn ^(b) 22(5.0%) TEAE leading to oral antidepressant 8 (1.8%) withdrawn ^(b) ^(a)Study drug relationships of possible, probable, and very likely areincluded in this category. ^(b) An adverse event that started in theinduction phase and resulted in discontinuation in a following phase iscounted as treatment-emergent in the induction phase. Incidence is basedon the number of subjects experiencing at least one adverse event, notthe number of events. Adverse events are coded using MedDRA version20.0.

TABLE 97 Overall Summary of Treatment-emergent Adverse Events (TEAE);Optimization Phase (Study ESKETINTRD3003: Safety (OP) Analysis Set)Intranasal Esk + Oral AD (N = 455) TEAE 335 (73.6%) TEAE possiblyrelated to intranasal drug ^(a) 281 (61.8%) TEAE possibly related tooral antidepressant ^(a) 61 (13.4%) TEAE leading to death 0 1 or moreserious TEAE 11 (2.4%) TEAE leading to intranasal drug withdrawn ^(b) 5(1.1%) TEAE leading to oral antidepressant 2 (0.4%) withdrawn ^(b) ^(a)Study drug relationships of possible, probable, and very likely areincluded in this category. ^(b) An adverse event that started in theoptimization phase and resulted in discontinuation in a following phaseis counted as treatment-emergent in the optimization phase. Incidence isbased on the number of subjects experiencing at least one adverse event,not the number of events. Adverse events are coded using MedDRA version20.0.

TABLE 98 Overall Summary of Treatment-emergent Adverse Events (TEAE);Maintenance Phase (Study ESKETINTRD3003: Safety (MA) Analysis Set)Intranasal Esk + Oral AD + Oral AD Intranasal Placebo (N = 152) (N =145) TEAE 125 (82.2%) 66 (45.5%) TEAE possibly related to intranasaldrug ^(a) 106 (69.7%) 37 (25.5%) TEAE possibly related to oralantidepressant ^(a) 13 (8.6%) 9 (6.2%) TEAE leading to death 0 0 SevereTEAE 12 (7.9%) 6 (4.1%) Moderate TEAE 72 (47.4%) 38 (26.2%) Mild TEAE 41(29%) 22 (15.2%) 1 or more serious TEAE 4 (2.6%) 1 (0.7%) TEAE leadingto intranasal drug withdrawn ^(b) 4 (2.6%) 3 (2.1%) TEAE leading to oralantidepressant withdrawn ^(b) 3 (2.0%) 0 ^(a) Study drug relationshipsof possible, probable, and very likely are included in this category.^(b) An adverse event that started in the maintenance phase and resultedin discontinuation in the follow-up phase is counted astreatment-emergent in the maintenance phase. Incidence is based on thenumber of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 20.0.

TEAEs for the transferred-entry subjects who continued to receive anoral AD+placebo during the OP and MA phase are summarized in the Tables99 and 100. Overall, 61.6% of TEP subjects experienced at least one TEAEduring the OP phase; 68.5% of TEP subjects experienced at least one TEAEduring the MA phase.

TABLE 99 Overall Summary of Treatment-emergent Adverse Events (TEAE);Optimization Phase (Study ESKETINTRD3003: Safety (OP_TEP) Analysis Set)Oral AD + Intranasal Placebo (N = 86) TEAE 53 (61.6%) TEAE possiblyrelated to intranasal drug ^(a) 27 (31.4%) TEAE possibly related to oral10 (11.6%) antidepressant ^(a) TEAE leading to death 0 1 or more seriousTEAE 0 TEAE leading to intranasal drug 0 withdrawn ^(b) TEAE leading tooral antidepressant 0 withdrawn ^(b) ^(a) Study drug relationships ofpossible, probable, and very likely are included in this category. ^(b)An adverse event that started in the optimization phase and resulted indiscontinuation in a following phase is counted as treatment-emergent inthe optimization phase. Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0.

TABLE 100 Overall Summary of Treatment-emergent Adverse Events (TEAE);Maintenance Phase (Study ESKETINTRD3003: Safety (MA_TEP) Analysis Set)Oral AD + Intranasal Placebo (N = 54) TEAE 37 (68.5%) TEAE possiblyrelated to intranasal drug ^(a) 19 (35.2%) TEAE possibly related to oral8 (14.8%) antidepressant ^(a) TEAE leading to death 0 1 or more seriousTEAE 1 (1.9%) TEAE leading to intranasal drug 2 (3.7%) withdrawn ^(b)TEAE leading to oral antidepressant 1 (1.9%) withdrawn ^(b) ^(a) Studydrug relationships of possible, probable, and very likely are includedin this category. ^(b) An adverse event that started in the maintenancephase and resulted in discontinuation in the follow-up phase is countedas treatment-emergent in the maintenance phase. Incidence is based onthe number of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 20.0.

Treatment-emergent adverse events occurring during the IND, OP and MAphase (≥5% of subjects in any treatment group) are summarized bytreatment group for the safety (IND), safety (OP) and safety (MA)analysis sets in Tables 101-103. The most common TEAEs (10%) during theIND phase were vertigo (22.7%), dizziness (22.2%), nausea (21.5%),dysgeusia (20.6%), somnolence (14.9%), headache (13.7%), paresthesia(11.0%), dissociation (11.0%), feeling abnormal (10.8%), vision blurred(10.3%) and sedation (10.1%) in the safety (IND) analysis set. The mostcommon TEAEs during the OP phase were vertigo (20.0%), dysgeusia(17.4%), somnolence (13.8%), dizziness (13.4%), headache (12.5%) andnausea (10.5%) in the safety (OP) analysis set. The most common TEAEs inthe esketamine+oral AD group during the double-blind MA phase weredysgeusia (26.3%), vertigo (25.0%), somnolence (21.1%), dizziness(20.4%), headache (17.8%), nausea (16.4%), vision blurred (15.8%),dissociation (13.8%) and hypoesthesia oral (13.2%) in the safety (MA)analysis set. There were no TEAEs in ≥10% of subjects with oralAD+placebo group in the safety (MA) analysis set. Most AEs were observedpost dose on dosing days and resolved on the same day.

TABLE 101 Treatment-emergent Adverse Events in at Least 5% of Subjects;Open-label Induction Phase (Study ESKETINTRD3003: Safety (IND) AnalysisSet) Intranasal Esk + Oral AD (N = 437) Total no. subjects with TEAE 336(76.9%) Nervous system disorders 247 (56.5%) Dizziness 97 (22.2%)Dysgeusia 90 (20.6%) Somnolence 65 (14.9%) Headache 60 (13.7%)Paresthesia 48 (11.0%) Sedation 44 (10.1%) Dizziness postural 30 (6.9%)Hypoesthesia 30 (6.9%) Psychiatric disorders 153 (35.0%) Dissociation 48(11.0%) Anxiety 31 (7.1%) Gastrointestinal disorders 150 (34.3%) Nausea94 (21.5%) Hypoesthesia oral 32 (7.3%) Vomiting 29 (6.6%) Ear andlabyrinth disorders 108 (24.7%) Vertigo 99 (22.7%) General disorders andadministration site 94 (21.5%) conditions Feeling abnormal 47 (10.8%)Respiratory, thoracic and mediastinal 87 (19.9%) disorders Nasaldiscomfort 28 (6.4%) Throat irritation 26 (5.9%) Eye disorders 65(14.9%) Vision blurred 45 (10.3%) Investigations 42 (9.6%) Bloodpressure increased 34 (7.8%) Incidence is based on the number ofsubjects experiencing at least one adverse event, not the number ofevents. Adverse events are coded using MedDRA version 20.0.

TABLE 102 Treatment-emergent Adverse Events in at Least 5% of Subjects;Optimization Phase (Study ESKETINTRD3003: Safety (OP) Analysis Set)Intranasal Esk + Oral AD (N = 455) Total no. subjects with TEAE 335(73.6%) Nervous system disorders 208 (45.7%) Dysgeusia 79 (17.4%)Somnolence 63 (13.8%) Dizziness 61 (13.4%) Headache 57 (12.5%) Dizzinesspostural 24 (5.3%) Hypoesthesia 24 (5.3%) Paresthesia 24 (5.3%)Psychiatric disorders 123 (27.0%) Dissociation 44 (9.7%)Gastrointestinal disorders 115 (25.3%) Nausea 48 (10.5%) Hypoesthesiaoral 34 (7.5%) Ear and labyrinth disorders 101 (22.2%) Vertigo 91(20.0%) Respiratory, thoracic and mediastinal 74 (16.3%) disorders Nasaldiscomfort 26 (5.7%) General disorders and administration site 65(14.3%) conditions Feeling abnormal 33 (7.3%) Investigations 48 (10.5%)Blood pressure increased 26 (5.7%) Eye disorders 46 (10.1%) Visionblurred 29 (6.4%) Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0.

TABLE 103 Treatment-emergent Adverse Events in at Least 5% of Subjectsin Either Treatment Group; Maintenance Phase (Study ESKETINTRD3003:Safety (MA) Analysis Set) Intranasal Esk + Oral AD + Oral AD IntranasalPlacebo (N = 152) (N = 145) Total no. subjects with TEAE 125 (82.2%) 66(45.5%) Nervous system disorders 83 (54.6%) 30 (20.7%) Dysgeusia 40(26.3%) 10 (6.9%) Somnolence 32 (21.1%) 3 (2.1%) Dizziness 31 (20.4%) 7(4.8%) Headache 27 (17.8%) 14 (9.7%) Paresthesia 12 (7.9%) 0 Sedation 10(6.6%) 1 (0.7%) Hypoesthesia 9 (5.9%) 1 (0.7%) Psychiatric disorders 56(36.8%) 15 (10.3%) Dissociation 21 (13.8%) 0 Anxiety 10 (6.6%) 5 (3.4%)Confusional state 8 (5.3%) 0 Gastrointestinal disorders 53 (34.9%) 11(7.6%) Nausea 25 (16.4%) 1 (0.7%) Hypoesthesia oral 20 (13.2%) 0Vomiting 10 (6.6%) 1 (0.7%) Paresthesia oral 8 (5.3%) 1 (0.7%) Ear andlabyrinth disorders 43 (28.3%) 9 (6.2%) Vertigo 38 (25.0%) 8 (5.5%) Eyedisorders 32 (21.1%) 1 (0.7%) Vision blurred 24 (15.8%) 1 (0.7%)Diplopia 9 (5.9%) 0 Infections and infestations 32 (21.1%) 25 (17.2%)Viral upper respiratory tract infection 11 (7.2%) 12 (8.3%) Respiratory,thoracic and mediastinal disorders 30 (19.7%) 11 (7.6%) Nasal discomfort11 (7.2%) 4 (2.8%) Throat irritation 8 (5.3%) 1 (0.7%) General disordersand administration site 28 (18.4%) 3 (2.1%) conditions Feeling abnormal14 (9.2%) 1 (0.7%) Investigations 19 (12.5%) 10 (6.9%) Blood pressureincreased 10 (6.6%) 5 (3.4%) Incidence is based on the number ofsubjects experiencing at least one adverse event, not the number ofevents. Adverse events are coded using MedDRA version 20.0.

Treatment-emergent adverse events occurring during the OP and MA phase(≥5% of subjects) for the TEP subjects are summarized for the safety(OP_TEP) and safety (MA_TEP) analysis sets in the Tables 104 and 105.The most common TEAEs for the TEP subjects during the OP phase washeadache (18.6%). The most common TEAEs for the TEP subjects during theMA phase were viral upper respiratory tract infection (24.1%), headache(22.2%) and dysgeusia (14.8%).

TABLE 104 Treatment-emergent Adverse Events in at Least 5% of Subjects;Optimization Phase (Study ESKETINTRD3003: Safety (OP_TEP) Analysis Set)Oral AD + Intranasal Placebo (N = 86) Total no. subjects with TEAE 53(61.6%) Nervous system disorders 30 (34.9%) Headache 16 (18.6%)Dysgeusia 8 (9.3%) Dizziness 6 (7.0%) Somnolence 5 (5.8%) Psychiatricdisorders 12 (14.0%) Anxiety 5 (5.8%) Incidence is based on the numberof subjects experiencing at least one adverse event, not the number ofevents. Adverse events are coded using MedDRA version 20.0.

TABLE 105 Treatment-emergent Adverse Events in at Least 5% of Subjects;Maintenance Phase (Study ESKETINTRD3003: Safety (MA_TEP) Analysis Set)Oral AD + Intranasal Placebo (N = 54) Total no. subjects with TEAE 37(68.5%) Infections and infestations 24 (44.4%) Viral upper respiratorytract infection 13 (24.1%) Urinary tract infection 3 (5.6%) Nervoussystem disorders 18 (33.3%) Headache 12 (22.2%) Dysgeusia 8 (14.8%)Somnolence 4 (7.4%) Gastrointestinal disorders 11 (20.4%) Diarrhea 4(7.4%) Nausea 3 (5.6%) Musculoskeletal and connective tissue 8 (14.8%)disorders Musculoskeletal pain 3 (5.6%) Spinal pain 3 (5.6%) Incidenceis based on the number of subjects experiencing at least one adverseevent, not the number of events. Adverse events are coded using MedDRAversion 20.0.

Adverse Events Leading to Study Drug Withdrawal

There were 22 subjects who discontinued the IND phase intranasal studymedication due to treatment-emergent adverse events (Table 106) and 8subjects who discontinued the oral AD medication due to TEAEs (Table107) in the safety (IND) analysis set. There were 5 subjects whodiscontinued the OP phase intranasal study medication due totreatment-emergent adverse events (Table 108) and 2 subjects whodiscontinued the oral AD medication due to TEAEs (Table 109) in thesafety (OP) analysis set. Subjects who discontinued intranasal studymedication could continue the oral AD in the follow-up phase ifappropriate.

TABLE 106 Treatment-emergent Adverse Events Leading to Discontinuationof Intranasal Study Medication; Open-label Induction Phase (StudyESKETINTRD3003: Safety (IND) Analysis Set) Intranasal Esk + Oral AD (N =437) Total no. subjects with TEAE leading to 22 (5.0%)  discontinuation^(a) Psychiatric disorders 11 (2.5%)  Anxiety 7 (1.6%) Depression 2(0.5%) Dissociation 2 (0.5%) Nightmare 1 (0.2%) Suicidal ideation 1(0.2%) Nervous system disorders 8 (1.8%) Akathisia 1 (0.2%) Autonomicnervous system imbalance 1 (0.2%) Dizziness postural 1 (0.2%) Headache 1(0.2%) Hypertonia 1 (0.2%) Lacunar stroke 1 (0.2%) Paresthesia 1 (0.2%)Sedation 1 (0.2%) Simple partial seizures 1 (0.2%) Tremor 1 (0.2%)General disorders and administration site 3 (0.7%) conditions Asthenia 1(0.2%) Chills 1 (0.2%) Feeling abnormal 1 (0.2%) Gastrointestinaldisorders 2 (0.5%) Nausea 2 (0.5%) Vomiting 1 (0.2%) Investigations 2(0.5%) Blood pressure increased 2 (0.5%) Musculoskeletal and connectivetissue disorders 2 (0.5%) Muscular weakness 1 (0.2%) Musculoskeletalstiffness 1 (0.2%) Ear and labyrinth disorders 1 (0.2%) Vertigo 1 (0.2%)Renal and urinary disorders 1 (0.2%) Micturition urgency 1 (0.2%)Respiratory, thoracic and mediastinal disorders 1 (0.2%) Dyspnea 1(0.2%) ^(a) An adverse event that started in the induction phase andresulted in discontinuation in a following phase is counted astreatment-emergent in the induction phase. Incidence is based on thenumber of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 20.0.

TABLE 107 Treatment-emergent Adverse Events Leading to Discontinuationof Oral Antidepressant; Open-label Induction Phase (StudyESKETINTRD3003: Safety (IND) Analysis Set) Intranasal Esk + Oral AD (N =437) Total no. subjects with TEAE leading to 8 (1.8%) discontinuation^(a) Psychiatric disorders 5 (1.1%) Depression 3 (0.7%) Anxiety 1 (0.2%)Suicidal ideation 1 (0.2%) Nervous system disorders 3 (0.7%) Headache 1(0.2%) Lacunar stroke 1 (0.2%) Tremor 1 (0.2%) Renal and urinarydisorders 1 (0.2%) Micturition urgency 1 (0.2%) ^(a) An adverse eventthat started in the induction phase and resulted in discontinuation in afollowing phase is counted as treatment-emergent in the induction phase.Incidence is based on the number of subjects experiencing at least oneadverse event, not the numbe of events. Adverse events are coded usingMedDRA version 20.0. 1 subject who had completed the Day 25 intranasalmedication and did not meet criteria for continuing to the next phase.The action taken for the adverse event (depression) was indicated asoral AD drug withdrawn. This subject is considered as a completer forthe summary of study completion/withdrawal for the induction phase.

TABLE 108 Treatment-emergent Adverse Events Leading to Discontinuationof Intranasal Study Medication; Optimization Phase (StudyESKETINTRD3003: Safety (OP) Analysis Set) Intranasal Esk + Oral AD (N =455) Total no. subjects with TEAE leading to 5 (1.1%) discontinuation^(a) Investigations 2 (0.4%) Gamma-glutamyltransferase increased 1(0.2%) Hepatic enzyme increased 1 (0.2%) Psychiatric disorders 2 (0.4%)Alcohol abuse 1 (0.2%) Depression 1 (0.2%) Ear and labyrinth disorders 1(0.2%) Tinnitus 1 (0.2%) ^(a) An adverse event that started in theoptimization phase and resulted in discontinuation in a following phaseis counted as treatment-emergent in the optimization phase. Incidence isbased on the number of subjects experiencing at least one adverse event,not the number of events. Adverse events are coded using MedDRA version20.0.

TABLE 109 Treatment-emergent Adverse Events Leading to Discontinuationof Oral Antidepressant; Optimization Phase (Study ESKETINTRD3003: Safety(OP) Analysis Set) Intranasal Esk + Oral AD (N = 455) Total no. subjectswith TEAE leading to 2 (0.4%) discontinuation ^(a) Investigations 1(0.2%) Hepatic enzyme increased 1 (0.2%) Psychiatric disorders 1 (0.2%)Deoression 1 (0.2%) ^(a) An adverse event that started in theoptimization phase and resulted in discontinuation in a following phaseis counted as treatment-emergent in the optimization phase. Incidence isbased on the number of subjects experiencing at least one adverse event,not the number of events. Adverse events are coded using MedDRA version20.0.

There were 7 subjects (4 subjects in esketamine+oral AD, 3 subjects inoral AD+placebo) who discontinued the MA phase intranasal studymedication due to treatment-emergent adverse events in the safety (MA)analysis set (Table 110). Four of these subjects (3 subjects inesketamine+oral AD, 1 subject in oral AD+placebo) had a relapse duringthe maintenance phase and indicated for the adverse event leading torelapse that the intranasal study medication was discontinued due tothis event. These subjects could continue the oral AD in the follow-upphase if appropriate. Three subjects in esketamine+oral AD armdiscontinued the MA phase oral antidepressant study medication due totreatment-emergent adverse events in the safety (MA) analysis set (Table111). These three subjects had a relapse during the maintenance phaseand indicated for the adverse event leading to relapse that the oral ADmedication was discontinued due to this event. No subjects in oral AD+intranasal placebo arm discontinued the MA phase oral AD studymedication due to treatment-emergent adverse events.

TABLE 110 Treatment-emergent Adverse Events Leading to Discontinuationof Intranasal Study Medication; Maintenance Phase (Study ESKETINTRD3003:Safety (MA) Analysis Set) Intranasal Esk + Oral AD + Oral AD IntranasalPlacebo (N = 152) (N = 145) Total no. subjects with TEAE 4 (2.6%) 3(2.1%) leading to discontinuation ^(a) Psychiatric disorders 4 (2.6%) 3(2.1%) Depression 3 (2.0%) 3 (2.1%) Confusional state 1 (0.7%) 0 ^(a) Anadverse event that started in the maintenance phase and resulted indiscontinuation in the follow-up phase is counted as treatment-emergentin the maintenance phase. Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0. 4 subjects (3 inesketamine + oral AD, 1 in oral AD + placebo) who had a relapse event(depression) are included in this summary. The action taken for therelapse adverse event was indicated as intranasal drug withdrawn. Theyare considered as completers for the summary of studycompletion/withdrawal for the maintenance phase.

TABLE 111 Treatment-emergent Adverse Events Leading to Discontinuationof Oral Antidepressant; Maintenance Phase (Study ESKETINTRD3003: Safety(MA) Analysis Set) Intranasal Esk + Oral AD + Oral AD Intranasal Placebo(N = 152) (N = 145) Total no. subjects with TEAE 3 (2.0%) 0 leading todiscontinuation ^(a) Psychiatric disorders 3 (2.0%) 0 Depression 3(2.0%) 0 ^(a) An adverse event that started in the maintenance phase andresulted in discontinuation in the follow-up phase is counted astreatment-emergent in the maintenance phase. Incidence is based on thenumber of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 20.0. 3subjects who had a relapse event are included in this summary. Theaction taken for the relapse adverse event was indicated as oral AD drugwithdrawn. They are considered as a completer for the summary of studycompletion/withdrawal for the maintenance phase.

There was no transferred-entry placebo subject who discontinued the OPphase intranasal study medication or oral AD due to treatment-emergentadverse events in the safety (OP_TEP) analysis set (Tables 112 and 113).

TABLE 112 Treatment-emergent Adverse Events Leading to Discontinuationof Intranasal Study Medication; Optimization Phase (StudyESKETINTRD3003: Safety (OP_TEP) Analysis Set) Oral AD + IntranasalPlacebo (N = 86) Total no. subjects with TEAE leading to 0discontinuation ^(a) No data to report ^(a) An adverse event thatstarted in the optimization phase and resulted in discontinuation in afollowing phase is counted as treatment-emergent in the optimizationphase. Incidence is based on the number of subjects experiencing atleast one adverse event, not the number of events. Adverse events arecoded using MedDRA version 20.0.

TABLE 113 Treatment-emergent Adverse Events Leading to Discontinuationof Oral Antidepressant; Optimization Phase (Study ESKETINTRD3003: Safety(OP_TEP) Analysis Set) Oral AD + Intranasal Placebo (N = 86) Total no.subjects with TEAE leading to 0 discontinuation ^(a) No data to report —^(a) An adverse event that started in the optimization phase andresulted in discontinuation in a following phase is counted astreatment-emergent in the optimization phase. Incidence is based on thenumber of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 20.0.

There were 2 transferred-entry placebo subjects who discontinued the MAphase intranasal study medication in the safety (MA_TEP) analysis set.One of these subjects discontinued the MA phase due to both intranasaland oral AD medications and is included in both Tables 114 and 115.

TABLE 114 Treatment-emergent Adverse Events Leading to Discontinuationof Intranasal Study Medication; Maintenance Phase (Study ESKETINTRD3003:Safety (MA_TEP) Analysis Set) Oral AD + Intranasal Placebo (N = 54)Total no. subjects with TEAE leading to 2 (3.7%) discontinuation ^(a)Infections and infestations 1 (1.9%) Nail infection 1 (1.9%)Investigations 1 (1.9%) Blood pressure increased 1 (1.9%) Skin andsubcutaneous tissue disorders 1 (1.9%) Butterfly rash 1 (1.9%) Rash 1(1.9%) ^(a) An adverse event that started in the maintenance phase andresulted in discontinuation in the follow-up phase is counted astreatment-emergent in the maintenance phase. Incidence is based on thenumber of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 20.0.

TABLE 115 Treatment-emergent Adverse Events Leading to Discontinuationof Oral Antidepressant; Maintenance Phase (Study ESKETINTRD3003: Safety(MA_TEP) Analysis Set) Oral AD + Intranasal Placebo (N = 54) Total no.subjects with TEAE leading to 1 (1.9%) discontinuation ^(a) Infectionsand infestations 1 (1.9%) Nail infection 1 (1.9%) Skin and subcutaneoustissue disorders 1 (1.9%) Butterfly rash 1 (1.9%) Rash 1 (1.9%) ^(a) Anadverse event that started in the maintenance phase and resulted indiscontinuation in the follow-up phase is counted as treatment-emergentin the maintenance phase. Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0.

Serious Adverse Events

There were no deaths reported in this study.

There were 32 subjects with 39 serious adverse events (SAEs) reported inthis study. A total of 13 subjects experienced serioustreatment-emergent adverse events (TEAEs) during the IND phase in thesafety (IND) analysis set (Table 116).

TABLE 116 Treatment-emergent Serious Adverse Events; Open-labelInduction Phase (Study ESKETINTRD3003: Safety (IND) Analysis Set)Intranasal Esk + Oral AD (N = 437) Total no. subjects with a seriousTEAE 13 (3.0%)  Psychiatric disorders 7 (1.6%) Depression 3 (0.7%)Anxiety 2 (0.5%) Disorientation 1 (0.2%) Suicidal ideation 1 (0.2%)Nervous system disorders 3 (0.7%) Autonomic nervous system imbalance 1(0.2%) Lacunar stroke 1 (0.2%) Sedation 1 (0.2%) Simple partial seizures1 (0.2%) General disorders and administration site 1 (0.2%) conditionsHypothermia 1 (0.2%) Injury, poisoning and procedural complications 1(0.2%) Procedural pain 1 (0.2%) Renal and urinary disorders 1 (0.2%)Nephrolithiasis 1 (0.2%) Vascular disorders 1 (0.2%) Orthostatichypotension 1 (0.2%) Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0.

Three subjects had serious TEAEs considered as of very likelyrelationship to intranasal esketamine by the investigators:disorientation (Day 1), suicidal ideation (Day 8), sedation (Day 22),and one subject had two serious TEAEs considered as of very likelyrelationship to intranasal esketamine: autonomic nervous systemimbalance (Day 5) and simple partial seizures (Day 5). One subject had aserious TEAE considered by the investigator as probably related tointranasal esketamine: lacunar stroke (Day 1). One subject had a seriousTEAE considered possibly related to intranasal esketamine: hypothermia(Day 10). Eleven subjects experienced serious treatment-emergent adverseevents during the OP phase in the safety (OP) analysis set (Table 117).No serious TEAEs were considered to be possibly, probably or very likelyrelated to esketamine.

TABLE 117 Treatment-emergent Serious Adverse Events; Optimization Phase(Study ESKETINTRD3003: Safety (OP) Analysis Set) Intranasal Esk + OralAD (N = 455) Total no. subjects with a serious TEAE 11 (2.4%)  Nervoussystem disorders 3 (0.7%) Headache 1 (0.2%) Migraine 1 (0.2%)Paresthesia 1 (0.2%) Infections and infestations 2 (0.4%) Pneumonia 1(0.2%) Sepsis 1 (0.2%) Psychiatric disorders 2 (0.4%) Depression 1(0.2%) Panic attack 1 (0.2%) Cardiac disorders 1 (0.2%) Sinustachycardia 1 (0.2%) Gastrointestinal disorders 1 (0.2%) Anal fissure 1(0.2%) General disorders and administration site 1 (0.2%) conditionsChest pain 1 (0.2%) Hepatobiliary disorders 1 (0.2%) Cholecystitis acute1 (0.2%) Musculoskeletal and connective tissue 1 (0.2%) disorders Painin extremity 1 (0.2%) Vascular disorders 1 (0.2%) Hypertensive crisis 1(0.2%) Incidence is based on the number of subjects experiencing atleast one adverse event, not the number of events. Adverse events arecoded using MedDRA version 20.0.

Five subjects (4 subjects in esketamine+oral AD, 1 subject in oralAD+placebo) in the safety (MA) analysis set experienced serioustreatment-emergent adverse events during the MA phase (Table 118). Allthe events were considered as not related to intranasal medication ororal AD.

TABLE 118 Treatment-emergent Serious Adverse Events; Maintenance Phase(Study ESKETINTRD3003: Safety (MA) Analysis Set) Oral AD + IntranasalEsk + Intranasal Placebo Oral AD (N = 152) (N = 145) Total no. subjectswith a serious 4 (2.6%) 1 (0.7%) TEAE Psychiatric disorders 3 (2.0%) 1(0.7%) Depression 2 (1.3%) 1 (0.7%) Major depression 1 (0.7%) 0Pregnancy, puerperium and 1 (0.7%) 0 perinatal conditions Ectopicpregnancy 1 (0.7%) 0 Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0.

Two subjects had serious AEs considered not related to oral AD in thefollow-up phase (Table 119). One subject experienced two serious AEsconsidered to be possibly related to oral AD.

TABLE 119 Serious Adverse Events; Follow-up Phase (Study ESKETINTRD3003:Follow-up Analysis Set) Intranasal Esk + Oral AD + Oral AD IntranasalPlacebo for Any Phase for All Phases (N = 481) (N = 64) Total no.subjects with a serious 3 (0.6%) 0 adverse event General disorders and 1(0.2%) 0 administration site conditions Chest pain 1 (0.2%) 0Musculoskeletal and connective 1 (0.2%) 0 tissue disordersIntervertebral disc protrusion 1 (0.2%) 0 Psychiatric disorders 1 (0.2%)0 Depression 1 (0.2%) 0 Mania 1 (0.2%) 0 Incidence is based on thenumber of subjects experiencing at least one adverse event, not thenumber of events. Adverse events are coded using MedDRA version 20.0.

There was no transferred-entry placebo subject who experienced a serioustreatment-emergent adverse event during the OP phase in the safety(OP_TEP) analysis set (Table 120).

TABLE 120 Treatment-emergent Serious Adverse Events; Optimization Phase(Study ESKETINTRD3003: Safety (OP_TEP) Analysis Set) Oral AD +Intranasal Placebo (N = 86) Total no. subjects with a serious TEAE 0 Nodata to report — Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0.

One TEP subject experienced a serious TEAE during the MA phase which wasconsidered not related to intranasal medication or oral AD Table 121).

TABLE 121 Treatment-emergent Serious Adverse Events; Maintenance Phase(Study ESKETINTRD3003: Safety (MA_TEP) Analysis Set) Oral AD +Intranasal Placebo (N = 54) Total no. subjects with a serious TEAE 1(1.9%) Injury, poisoning and procedural 1 (1.9%) complications Claviclefracture 1 (1.9%) Incidence is based on the number of subjectsexperiencing at least one adverse event, not the number of events.Adverse events are coded using MedDRA version 20.0.

Vital Signs

FIGS. 53 and 54 present means for blood pressure over time by treatmentgroup in the maintenance phase.

Transient blood pressure increases peaked for the esketamine group atapproximately 40 minutes post dose and returned closer to predose levelsby 1.5 hours post dose.

Other Safety Observations Clinician-Assessed Dissociative Symptom Scale(CADSS)

The Clinician Administered Dissociative States Scale (CADSS) wasmeasured prior to the start of each dose, at 40 minutes, and 1.5 hourspostdose. The CADSS is used to assess treatment emergent dissociativesymptoms and perceptual changes and the total score ranges from 0 to 92with a higher score representing a more severe condition.

The dissociative and perceptual change symptoms measured by the CADSS,suggest these symptoms had an onset shortly after the start of the doseand resolved by 1.5 hours postdose (FIG. 55).

Modified Observer's Assessment of Alertness/Sedation (MOAA/S)

The Modified Observer's Assessment of Alertness/Sedation (MOAA/S) wasused to measure treatment-emergent sedation with correlation to levelsof sedation defined by the American Society of Anesthesiologists (ASA)continuum. The MOAA/S scores range from 0 (No response to painfulstimulus; corresponds to ASA continuum for general anesthesia) to 5(Readily responds to name spoken in normal tone [awake]; corresponds toASA continuum for minimal sedation).

The proportion of subjects with sedation (as measured by the MOAA/Sscale ≤3) was ≤3.9% for esketamine+oral AD for each dosing day in allphases.

Conclusions

Continued treatment with esketamine plus an oral AD demonstratedstatistically significant superiority to treatment with an oral AD plusintranasal placebo in delaying time to relapse in those who were instable remission after 16 weeks of treatment with esketamine plus anoral AD.

In subjects who were in stable remission after 16 weeks ofesketamine+oral AD treatment, continued treatment with esketamine plusan oral AD demonstrated clinically meaningful and statisticallysignificant (two-sided p=0.003) superiority to treatment with an oralAD+placebo nasal spray as measured by delayed time to relapse.

Overall, 26.7% subjects on esketamine+oral AD and 45.3% subjects on anoral AD+placebo nasal spray experienced a relapse; the 6-month relapserates based on Kaplan Meier estimates were 34.5% and 48.6%,respectively. The estimated hazard ratio (95% CI) of esketamine+oral ADrelative to oral AD+placebo based on weighted estimates was 0.49 (0.29,0.84), indicating, that at any time point during the study period,subjects who were stable remitters and continued treatment withesketamine+oral AD group were on average 51% less likely to relapse thansubjects who switched to oral AD plus placebo. Based on Kaplan-Meierestimates, median time to relapse (time point at which the cumulativesurvival function equals 0.5 [or 50%]) for esketamine plus oral AD armwas not estimable (NE) as this group never reached 50%. The median timeto relapse (95% CI) for oral AD plus placebo nasal spray was 273 (97.0;NE) days.

In subjects who are in stable response (but not In remission) after 16weeks of esketamine+oral AD treatment, continued treatment withesketamine plus an oral AD demonstrated clinically meaningful andstatistically significant superiority to an oral AD plus placebo nasalspray in delaying time to relapse (two-sided p<0.001).

The 6-month relapse rates based on Kaplan Meier estimates were 24.4% and59.4%, respectively. The estimated hazard ratio of intranasalesketamine+oral AD relative to oral AD plus placebo nasal spray based onCox proportional hazards model was 0.30 (95% CI: 0.16, 0.55), indicatingthat, at any time point during the study period, subjects who werestable responders and continued treatment with esketamine+oral AD groupwere on average 70% less likely to have a relapse than subjects whoswitched to the oral AD plus placebo nasal spray. Of note, the estimateof the median time to relapse for esketamine plus oral AD should beinterpreted with caution as it is heavily influenced by one subject whohad a long time to relapse (i.e. 635 days).

As shown, continued treatment with esketamine plus an oral ADdemonstrated statistically significant superiority to treatment with anoral AD alone in delaying time to relapse in those who were in stableresponse (but not remission) after 16 weeks of treatment with esketamineplus an oral AD.

Example 5 Treatment Duration/Trial Duration

Each subject participated in up to 4 phases: up to 4-week screeningphase (direct-entry subjects only), a 4-week open-label induction (IND)phase (direct-entry subjects and transferred-entry non respondersubjects), a 48-week open-label optimization/maintenance (OP/MA) phase(all responder subjects from the open label IND phase of the currentstudy, and transferred-entry responder subjects), and a 4-week follow-upphase. The maximum duration of the subject's participation inESKETINTRD3004 study was 60 weeks for direct-entry subjects; 56 weeksfor transferred-entry non-responder subjects, and 52 weeks fortransferred-entry responder subjects. The sample size of 750 wasestimated to have at least 300 subjects received treatment withintranasal esketamine for 6 months and at least 100 subjects for 12months. In addition, transfer-entry subjects were enrolled from 3005study to get 100 elderly subjects dosed with esketamine. See, FIG. 57for the trial design.

Analysis Sets for Efficacy and Safety

The efficacy and safety analyses are based on the full (IND) analysisset and the full (OP/MA) analysis set. The full (IND) analysis set isdefined as all subjects who receive at least 1 dose of intranasal studymedication or 1 dose of oral antidepressant in the open-label IND phase(for direct-entry and transferred-entry non-responder subjects). Thefull (OP/MA) analysis is defined as all subjects who receive at least 1dose of intranasal study medication or 1 dose of oral antidepressant inthe OP/MA phase. Safety variables include cognition function over time,treatment-emergent adverse events (TEAEs), including TEAEs of specialinterest, vital signs over time, Clinician-Administered DissociativeSymptom Scale (CADDS) over time, and Modified Observer's Assessment ofAlertness/Sedation (MOAA/S) score ≤3. Efficacy variables include theMADRS which consists of 10 items that cover all the core depressivesymptoms: each item is scored from 0 (symptom is not present or isnormal) to 6 (severe or continuous presence of the symptom). A totalscore (0 to 60) is calculated by summing the scores of all 10 items. Ahigher score represents a more severe condition.

Primary Objective

The primary objective of this study is to assess the long-term safetyand tolerability of intranasal esketamine plus a newly initiated oralantidepressant in subjects with TRD, with special attention to thepotential effects on cognitive function, potential treatment-emergentsymptoms of cystitis and/or lower urinary tract symptoms, and potentialwithdrawal and/or rebound symptoms following cessation of intranasalesketamine treatment.

Secondary Objectives

To assess the effect of intranasal esketamine plus a newly initiatedoral antidepressant in subjects with TRD on:

Safety and tolerability with special attention to the following:

-   -   Treatment-emergent adverse events (TEAEs), including TEAEs of        special interest    -   Local nasal tolerability    -   Effects on heart rate, blood pressure, respiratory rate and        blood oxygen saturation    -   Effects on alertness and sedation    -   Potential psychorespiratory    -   sis-like effects    -   Dissociative symptoms

Potential effects on suicidal ideation/behavior.

Long-term efficacy, including effects on:

Depressive symptoms (clinician and self-reported), overall severity ofdepressive illness, functional impairment and associated disability,anxiety symptoms, and health-related quality of life and health status

Response rate over time, defined as:

-   -   percentage of subjects with 50% reduction from baseline (IND        phase) in the Montgomery-Asberg Depression Rating Scale (MADRS)        total score,    -   percentage of subjects with 250% reduction from baseline (IND        phase) in the Patient Health Questionnaire, 9-item (PHQ-9) total        score

Remission rate overtime, defined as:

-   -   percentage of subjects with MADRS total score ≤12,    -   percentage of subjects with PHQ-9 total score ≤5

Subject and Treatment Information

A total of 1161 subjects were screened or enrolled across 123 sites in21 countries (Argentina, Australia, Austria, Belgium, Brazil, Bulgaria,Finland, France, Germany, Italy, Republic of Korea, Malaysia, Mexico,Poland, South Africa, Spain, Sweden, Taiwan, Turkey, United Kingdom, andUnited States). Excluding 338 screen failures and 21 subjects from siteUS10025 due to GCP issues, 802 subjects with a DSM-5 (Diagnostic andStatistical Manual of Mental Disorders, 5th Edition) diagnosis of MDDwere enrolled.

Six hundred ninety-one subjects were directly enrolled into the 3004study and 111 subjects were transferred from the TRD3005 study (88non-responders and 23 responders).

This is an open-label, multicenter, long-term study to evaluate thesafety and efficacy of intranasal esketamine plus a newly initiated oralantidepressant in subjects with TRD. The study included 802 enrolledmale and female adult subjects with TRD. Of the 802 enrolled subjects,691 (86.2%) were direct-entry subjects and 111 (13.8%) weretransfer-entry subjects from study ESKETINTRD3005 (88 werenon-responders entering the IND phase and 23 were responders enteringthe study in the OP/MA phase). In the all enrolled analysis set, 686(85.5%) of the subjects were white and 502 (62.6%) of the subjects werefemale. The mean age was 52.2 years, ranging from 18 to 86 years. Thegender distribution was similar to acute phase 3 studies (predominantlyfemale), while the median age was somewhat higher, reflecting inclusionof elderly subjects. With 178 elderly subjects accounting for 22.2% ofthe enrolled analysis set, the study satisfied regulatory requirementswith a minimum 100 elderly subjects enrolled.

Out of 779 direct entry or transfer-entry non-responder subjects fromthe TRD3005 study in the full (IND) analysis set, 580 (74.5%) completedthe IND phase and 198 (25.4%) withdrew early. The majority of subjectswere discontinued from the IND phase due to subject ‘did not meetcriteria for continuing into the next phase’ (84 subjects) and ‘adverseevent’ (52 subjects). Of the 603 subjects entered in the OP/MA phase(including 23 transfer entry responders from the TRD3005 study), 150(24.9%) completed OP/MA phase. Of the 453 subjects discontinued prior tothe end of the 48-week OP/MA phase, 331 were discontinued due totermination of the study by the sponsor (required number of subjects metsufficient treatment exposure). The other most frequent reasons fordiscontinuation were due ‘withdrawal by subject’(30 subjects), andwithdrew due to ‘adverse event’ and ‘lack of efficacy’ (25 subjectseach). Subjects could enter the follow-up phase from either the INDphase or the OP/MA phase. A total of 357 subjected entered the follow-upphase and 326 (91.3%) completed the follow-up phase.

Of the 802 enrolled subjects, 1 subject did not receive intranasal studydrug but did receive oral AD and subject received intranasal study drugbut did not receive oral AD. These subjects are included in the allenrolled analysis set. See, Tables 122 and 123.

TABLE 122 Number of Subjects Entered from Study ESKETINTRD3005 (ByResponder Status) and Direct Entry Subjects (Study ESKETINTRD3004: AllEnrolled Analysis Set) Intranasal Esk + Oral AD (N = 802) Direct-entrysubjects in study ESKETINTRD3004 691 (86.2%) Transferred-entry subjectsfrom study ESKETINTRD3005: 111 (13.8%) Non-responder subjects 88 (11.0%)Intranasal esk 28 mg + oral AD 3 (0.4%) Intranasal esk 56 mg + oral AD 9(1.1%) Intranasal esk 84 mg + oral AD 28 (3.5%) Oral AD + Placebo 48(6.0%) Responder subjects 23 (2.9%) Intranasal esk 28 mg + oral AD 1(0.1%) Intranasal esk 56 mg + oral AD 5 (0.6%) Intranasal esk 84 mg +oral AD 9 (1.1%) Oral AD + Placebo 8 (1.0%) The final dose in theTRD3005 study is presented for the Transferred-entry subjects.

TABLE 123 Number of Subjects in Each Analysis Set (Study ESKETINTRD3004:All Enrolled Analysis Set) Intranasal Esk + Oral AD (N = 802) Inductionphase Full (IND) 779 (97.1%) Optimization/maintenance phase Full (OP/MA)603 (75.2%) Follow-up phase Follow-up 357 (44.5%)

Subjects received flexible doses of intranasal ESK for the 1^(st) 2weeks, followed by fixed doses (28 mg—in elderly subjects only, 56 mg or84 mg in all age groups) plus a newly initiated oral antidepressant (oneof the following: sertraline, escitalopram, venlafaxine XR orfluoxetine). Esketamine was dosed twice a week during the IND. In theOP/MA weekly administration occurred from weeks 5 to 8. From weeks 9 to52 of the OP/MA phase, esketamine was dosed either weekly or every otherweek depending on the MADRS score with the aim of having the lowestfrequency to sustain remission. Switching to every other week treatment(if total MADRS score was ≤12) or back to weekly treatment (if totalMADRS score was >12) was possible at 4-week intervals, starting at week8. From day 15 (patients <65 years) or day 18 (patients ≥65 years) thedose of esketamine nasal spray remained the same. After an initialperiod of dose up-titration, the dose of oral antidepressants remainedthe same. Dose reductions based on tolerability were allowed for bothmedications.

The subject's discharge readiness was assessed based on overall adverseevents (including dizziness, sedation, perceptual changes, bloodpressure): Approximately 60-65% of the subjects were ready for dischargeby 1 hour after dosing and over 95% of subjects were ready for discharge1.5 h post dose across the visits of the IND phase; the percentages ofsubjects ready to discharge were approximately 65-70% 1 hour post doseand 97-99% 1.5 h post dose in the OP/MA phase.

Study Completion Withdrawal Information

Of the 779 full (IND) analysis set subjects (direct entry and transferentry non-responders), 580 (74.5%) subjects completed the 28-day INDphase and 198 (25.4%) withdrew early. Results are presented in Table124. The majority of subjects were discontinued from the IND phase dueto subject ‘did not meet criteria for continuing into the next phase’(<50% improvement in MADRS total score) (84 subjects) and ‘adverseevent’ (52 subjects).

TABLE 124 Completion/Withdrawal Information; Induction Phase (StudyESKETINTRD3004: Full (IND) Analysis Set) Intranasal Esk + Oral AD (N =779) Continued to optimization/maintenance phase 580 (74.5%) Withdrawnduring induction phase 198 (25.4%) Subject does not meet criteria forcontinuing 84 (10.8%) into the next phase Adverse event 52 (6.7%)Withdrawal by subject 22 (2.8%) Lack of efficacy 21 (2.7%) Lost tofollow-up 5 (0.6%) Non-compliance with study drug 1 (0.1%) Protocolviolation 1 (0.1%) Other 12 (1.5%) One subject was dispensed studymedication in OP/MA phase, but never took the drug in the OP/MA phase.This subject is not counted as continuing into the OP/MA phase sincedrug was not taken, but was discontinued in this phase.

Of the 603 subjects entering the OP/MA phase (including 23 transferentry responders from the TRD3005 study), 150 (24.9%) subjects completedthe 48-week OP/MA phase. Of the 453 subjects discontinued prior to theend of the 48-week OP/MA phase, 331 were discontinued due to terminationof the study by the sponsor (required number of subjects met sufficienttreatment exposure). Results are presented in Table 125. The mostfrequent reasons for discontinuation were due to ‘study terminated bysponsor’ (331 subjects), ‘withdrawal by subject’ (30 subjects), andwithdrew due to ‘adverse event’ and ‘lack of efficacy’ (25 subjectseach). (Note: the study was terminated after meeting esketamine exposuretargets (at least 300 subjects treated for 6 months and 100 subjectstreated for 12 months).

TABLE 125 Completion/Withdrawal Information; Optimization/MaintenancePhase (Study ESKETINTRD3004: Full (OP/MA) Analysis Set) Intranasal Esk +Oral AD (N = 603) Completed optimization/maintenance phase 150 (24.9%)Withdrawn during optimization/maintenance 453 (75.1%) phase Studyterminated by sponsor 331 (54.9%) Withdrawal by subject 30 (5.0%)Adverse event 25 (4.1%) Lack of efficacy 25 (4.1%) Lost to follow-up 10(1.7%) Protocol violation 3 (0.5%) Subject missed assessments ortreatment 3 (0.5%) sessions Death 2 (0.3%) Pregnancy 2 (0.3%)Non-compliance with study drug 1 (0.2%) Other 21 (3.5%)

Subjects could enter the follow-up phase from either the IND phase orthe OP/MA phase. A total of 357 subjected entered the follow-up phaseand 326 (91.3%) completed the follow-up phase.

2 subjects were discontinued from treatment during the OP/MA phase.Following the last menstruation, one subject was exposed twice to 56 mgESK dose and the 2^(nd) subject was exposed once to ESK 84 mg dose. Bothpregnancies spontaneously aborted during the first trimester, theinvestigator evaluation of causality to esketamine was not applicable.One case of paternal exposure to esketamine occurred during the study.The partner of subject had an uncomplicated pregnancy and delivered anormal mature female newborn via spontaneous delivery.

Demographic and Baseline Characteristics

Demographic and baseline characteristics are displayed in Table 126 forthe all enrolled analysis set. The majority of subjects entering thestudy were female (62.6%) and white (85.5%). The mean (SD) age of allsubjects was 52.2 (13.69) years, ranging from 18 to 86 years.

TABLE 126 Demographic and Baseline(IND) Characteristics (StudyESKETINTRD3004: All Enrolled Analysis Set) Intranasal Esk + Oral AD (N =802) Age (years) N 802 Mean (SD) 52.2 (13.69) Median   53.5 Range (18;86) Age category (years), n (%) N 802 18-44 225 (28.1%) 45-64 399(49.8%) 65-74 159 (19.8%) ≥75 19 (2.4%) Sex, n (%) N 802 Male 300(37.4%) Female 502 (62.6%) Race, n (%) N 802 Asian 81 (10.1%) Black orAfrican American 15 (1.9%) White 686 (85.5%) Other 8 (1.0%) Multiple 8(1.0%) Not Reported 4 (0.5%) Ethnicity, n (%) N 802 Hispanic or Latino149 (18.6%) Not Hispanic or Latino 640 (79.8%) Not Reported 10 (1.2%)Unknown 3 (0.4%) Baseline weight (kg) N 802 Mean (SD) 78.51 (18.426)Median    76.05 Range  (39.0; 143.0) Baseline height (cm) N 802 Mean(SD) 167.46 (10.340) Median   166.50 Range (139.7; 196.0) Baseline bodymass index (kg/m²) N 802 Mean (SD) 27.9 (5.68) Median   26.9 Range (16;52) BMI category (kg/m²), n (%) N 802 Underweight <18.5 9 (1.1%) Normal18.5-<25 262 (32.7%) Overweight 25-<30 275 (34.3%) Obese 30-<40 228(28.4%) Morbidly obese ≥40 28 (3.5%) Employment status, n (%) ^(a) N 802Any type of employment 450 (56.1%) Any type of unemployment 175 (21.8%)Other 177 (22.1%) Hypertension status, n (%) ^(b) N 802 Yes 220 (27.4%)No 582 (72.6%) Country, n (%) N 802 Argentina 106 (13.2%) Australia 23(2.9%) Austria 16 (2.0%) Belgium 5 (0.6%) Brazil 52 (6.5%) Bulgaria 94(11.7%) Finland 2 (0.2%) France 4 (0.5%) Germany 13 (1.6%) Italy 7(0.9%) Korea, Republic of 26 (3.2%) Malaysia 19 (2.4%) Mexico 10 (1.2%)Poland 6 (0.7%) South Africa 64 (8.0%) Spain 42 (5.2%) Sweden 90 (11.2%)Taiwan, Province of China 33 (4.1%) Turkey 31 (3.9%) United Kingdom 12(1.5%) United States 147 (18.3%) Region, n (%) N 802 Europe 322 (40.1%)North America 147 (18.3%) Other 333 (41.5%) Class of oralantidepressant, n (%) N 801 SNRI 407 (50.8%) SSRI 394 (49.2%) Oralantidepressant, n (%) N 801 Duloxetine 251 (31.3%) Escitalopram 237(29.6%) Sertraline 157 (19.6%) Venlafaxine extended release (XR) 156(19.5%) ^(a) Any type of employment includes: any category containing“Employed”, Sheltered Work, Housewife or Dependent Husband, and Student;any type of unemployment includes: any category containing “Unemployed”;Other includes: Retired and No Information Available. ^(b) Hypertensionstatus is classified as Yes if hypertension is recorded in medicalhistory.

Baseline psychiatric history for the all enrolled analysis set ispresented in Table 127. The mean (SD) baseline MADRS total score was31.4 (5.39), ranging from 19 to 49.

TABLE 127 Baseline(IND) Psychiatric History (Study ESKETINTRD3004: AllEnrolled Analysis Set) Intranasal Esk + Oral AD (N = 802) Age whendiagnosed with MDD (years) N 802 Mean (SD) 35.7 (13.75) Median   35.0Range  (8; 72) Baseline MADRS total score N 802 Mean (SD) 31.4 (5.39)Median   31.0 Range (19; 49) Baseline CGI-S N 802 Mean (SD) 4.8 (0.77)Median    5.0 Range (1; 7) Baseline CGI-S category, n (%) N 802 Normal,not at all ill 1 (0.1%) Borderline mentally ill 3 (0.4%) Mildly ill 18(2.2%) Moderately ill 235 (29.3%) Markedly ill 409 (51.0%) Severely ill130 (16.2%) Among the most extremely ill patients 6 (0.7%) BaselinePHQ-9 total score N 802 Mean (SD) 17.3 (5.01) Median   18.0 Range  (0;27) Screening C-SSRS lifetime ^(a), n (%) N 800 No event 474 (59.3%)Suicidal ideation 203 (25.4%) Suicidal behavior 123 (15.4%) ScreeningC-SSRS past 6 or 12 months ^(a), n (%) N 800 No event 583 (72.9%)Suicidal ideation (past 6 months) 215 (26.9%) Suicidal behavior (past 12months) 2 (0.3%) Duration of current episode (wks) N 802 Mean (SD) 160.5(261.80) Median   66.5 Range   (6; 2184) No. of previous antidepressantmedications ^(b c), n (%) N 802 1 17 (2.1%) 2 465 (58.0%) 3 187 (23.3%)4 84 (10.5%) 5 23 (2.9%) 6 17 (2.1%) 7 4 (0.5%) 8 5 (0.6%) Familyhistory of depression, n (%) N 802 Yes 346 (43.1%) No 456 (56.9%) Familyhistory of anxiety disorder, n (%) N 802 Yes 61 (7.6%) No 741 (92.4%)Family history of bipolar disorder, n (%) N 802 Yes 35 (4.4%) No 767(95.6%) Family history of schizophrenia, n (%) N 802 Yes 38 (4.7%) No764 (95.3%) Family history of alcohol abuse, n (%) N 802 Yes 61 (7.6%)No 741 (92.4%) Family history of substance abuse, n (%) N 802 Yes 24(3.0%) No 778 (97.0%) Number of prior ADs with nonresponse 1 = 2.1% ^(d)3 = 23.3% 2 = 58.0% ≥4 = 16.6% Baseline (IND) is the last observationprior to or on the start date of induction phase for direct-entry andtransferred-entry non-responder subjects and is baseline (IND) fromstudy 3005 for the transferred-entry responder subjects. ^(a) C-SSRScategory: No event = 0; Suicidal ideation = 1, 2, 3, 4, 5; Suicidalbehavior = 6, 7, 8,9, 10 ^(b) Number of antidepressant medications withnon-response (defined as ≤25% improvement or 26%-<50% improvement fordirect entry subjects and defined as ≤25% improvement for transfer entrysubjects) taken for at least 6 weeks during the current episode asobtained from MGH-ATRQ at the time of the first screening visit. ^(c)Direct entry subjects are to have to ≥2 oral antidepressant treatmentsin the current episode of depression and transfer entry subjects are tohave ≥1 oral antidepressants in the current episode. ^(d) Subjects from3005 who had non-response to 1 AD and showed prospective non-response to2^(nd) AD during screening of the 3005 study.

Extent of Exposure

The number of doses of intranasal study medication during the IND phaseis summarized in Table 128.

TABLE 128 Number of Days Dosed with Intranasal Study Medication;Induction Phase (Study ESKETINTRD3004: Full (IND) Analysis Set)Intranasal Esk + Oral AD Number of days dosed (N = 779) 1 29 (3.7%) 2 24(3.1%) 3 12 (1.5%) 4 11 (1.4%) 5  6 (0.8%) 6 22 (2.8%) 7 52 (6.7%) 8 622(79.8%)

A summary of mean, mode and final dose of intranasal study medicationduring the IND phase is summarized in Table 129. On Day 25 of the INDphase 28/675 (4.1%) were receiving the 28 mg dose of esketamine, 298/675(44.1%) were receiving the 56 mg dose of esketamine and 349/675 (51.7%)were receiving the 84 mg dose of esketamine.

TABLE 129 Mean, Mode, and Final Daily Dose of Intranasal StudyMedication; Induction Phase (Study ESKETINTRD3004: Full (IND) AnalysisSet) Intranasal Esk + Oral AD (N = 779) Mean daily dose (mg) N 778 Mean(SD) 64.4 (13.15) Median   63.0 Range (28; 81) Mode daily dose (mg) N741 Mean (SD) 68.5 (16.51) Median   56.0 Range (28; 84) Final daily dose(mg) N 778 Mean (SD) 68.2 (16.61) Median   56.0 Range (28; 84) Thecalculation of mean, mode, and final daily dose excludes days offintranasal study medication. The final dose is the last non-zero dosereceived during the induction phase.

The extent of exposure to intranasal study medication during thecombined IND and OP/MA phases is summarized in Table 130.

TABLE 130 Extent of Exposure to Intranasal Study Medication; Inductionand Optimization/Maintenance Phases (Study ESKETINTRD3004: All EnrolledAnalysis Set) Intranasal Esk + Oral AD Total Cumulative DurationDistribution (N = 802) (N = 802) Duration, weeks N 801 801 Category, n(%) ≤Week 4 (≤Day 28) 202 (25.2%) 202 (25.2%) Weeks 4-8 (Days 29-56) 35(4.4%) 237 (29.6%) Weeks 8-12 (Days 57-84) 23 (2.9%) 260 (32.4%) Weeks12-16 (Days 85-112) 48 (6.0%) 308 (38.4%) Weeks 16-20 (Days 113-140) 52(6.5%) 360 (44.9%) Weeks 20-24 (Days 141-168) 50 (6.2%) 410 (51.1%)Weeks 24-28 (Days 169-196) 52 (6.5%) 462 (57.6%) Weeks 28-32 (Days197-224) 34 (4.2%) 496 (61.8%) Weeks 32-36 (Days 225-252) 30 (3.7%) 526(65.6%) Weeks 36-40 (Days 253-280) 32 (4.0%) 558 (69.6%) Weeks 40-44(Days 281-308) 45 (5.6%) 603 (75.2%) Weeks 44-48 (Days 309-336) 35(4.4%) 638 (79.6%) Weeks 48-52 (Days 337-364) 155 (19.4%) 793(98.9%) >Week 52 (>Day 364) 8 (1.0%) 801 (99.9%) Mean (SD) 24.9 (18.54)Median   22.9 Range (0; 56) The duration of exposure is defined as theduration between the date of the first exposure and the date of the lastexposure to intranasal study medication. It includes days on whichsubjects did not actually take intranasal study medication.

The frequency of subjects with 6 months and 12 months of exposure toesketamine is presented in Table 131.

TABLE 131 Frequency Distribution of Subjects with 6 Months and 12 Monthsof Exposure to Intranasal Study Medication (Study ESKETINTRD3004: AllEnrolled Analysis Set) Intranasal Esk + Oral AD (N = 802) Subjects with6 months of exposure 364 (45.4%) Subjects with 12 months of exposure 136(17.0%) 6 months is defined as ≥180 days and 12 months is defined as≥350 days.

A summary of mean, mode and final dose of intranasal study medicationduring the OP/MA phase is summarized in Table 132.

TABLE 132 Mean, Mode, and Final Daily Dose of Intranasal StudyMedication; Optimization/Maintenance Phase (Study ESKETINTRD3004: Full(OP/MA) Analysis Set) Intranasal Esk + Oral AD (N = 603) Mean daily dose(mg) N 603   Mean (SD) 68.8 (15.74) Median 68.3 Range (25; 84) Modedaily dose (mg) N 596   Mean (SD) 69.1 (15.75) Median 70.0 Range (28;84) Final daily dose (mg) N 603   Mean (SD) 69.0 (16.05) Median 84.0Range (28; 84) The calculation of mean, mode, and final daily doseexcludes days off intranasal study medication. The final dose is thelast non-zero dose received during the optimization/maintenance phase.

On Week 48 of the OP/MA phase, 7/143 (4.9%), 69/143 (48.3%), 1/143(0.7%) and 66/143 (46.2%) were receiving the 28 mg dose, 56 mg dose, 70mg dose, and 84 mg dose of esketamine, respectively. Starting from Week4 (OP/MA), the intranasal treatment session frequency could be adjusted(if applicable) at fixed, 4-week intervals. Of the 603 subjects treatedwith intranasal esketamine during the OP/MA phase, 275 (47.6%) subjectsswitched from weekly dosing to every other week at Week 4 (OP/MA). Themajority of subjects did not switch dosing schedules during theremaining weeks of the OP/MA phase. See, Table 133.

TABLE 133 Frequency of Subjects who Changed the Dosing Frequency (Weeklyto Every Other Week or Every Other Week to Weekly) Over Time StartingFrom Week 4 (OP/MA) of this Phase; Optimization/Maintenance Phase (StudyESKETINTRD3004: Full (OP/MA) Analysis Set) Intranasal Esk + Oral AD (N =603) Week 4(OP/MA) N 578 Weekly to Every Other Week 275 (47.6%) EveryOther Week to Weekly  0 Did not switch 303 (52.4%) Week 8(OP/MA) N 548Weekly to Every Other Week 80 (14.6%) Every Other Week to Weekly 65(11.9%) Did not switch 403 (73.5%) Week 12(OP/MA) N 502 Weekly to EveryOther Week 76 (15.1%) Every Other Week to Weekly 52 (10.4%) Did notswitch 374 (74.5%) Week 16(OP/MA) N 463 Weekly to Every Other Week 58(12.5%) Every Other Week to Weekly 43 (9.3%) Did not switch 362 (78.2%)Week 20(OP/MA) N 405 Weekly to Every Other Week 34 (8.4%) Every OtherWeek to Weekly 29 (7.2%) Did not switch 342 (84.4%) Week 24(OP/MA) N 357Weekly to Every Other Week 23 (6.4%) Every Other Week to Weekly 42(11.8%) Did not switch 292 (81.8%) Week 28(OP/MA) N 309 Weekly to EveryOther Week 28 (9.1%) Every Other Week to Weekly 22 (7.1%) Did not switch259 (83.8%) Week 32(OP/MA) N 287 Weekly to Every Other Week 30 (10.5%)Every Other Week to Weekly 21 (7.3%) Did not switch 236 (82.2%) Week36(OP/MA) N 254 Weekly to Every Other Week 13 (5.1%) Every Other Week toWeekly 17 (6.7%) Did not switch 224 (88.2%) Week 40(OP/MA) N 211 Weeklyto Every Other Week 13 (6.2%) Every Other Week to Weekly 14 (6.6%) Didnot switch 184 (87.2%) Week 44(OP/MA) N 173 Weekly to Every Other Week 9(5.2%) Every Other Week to Weekly 6 (3.5%) Did not switch 158 (91.3%)

Table 134A displays the dosing regimen changes during the OP/MA phase.

TABLE 134A Dosing Regimen Changes; Optimization/Maintenance Phase (StudyESKETINTRD3004: Full (OP/MA) Analysis Set) Intranasal Esk + Oral AD (N =603) Total number of dosing regimen changes per subject N 603 0 145(24.0%) 1 230 (38.1%) 2 85 (14.1%) 3 70 (11.6%) 4 35 (5.8%) 5 28 (4.6%)6 10 (1.7%) ^(a) Dosing Regimen N 603 Weekly dose throughout entireOP/MA phase 145 (24.0%) One change only from weekly to every other week230 (38.1%) Change back and forth from weekly to every other 228 (37.8%)week The denominator is the number of subjects who have dosing ≥ Week4(OP/MA) Regimen: weekly esketamine dosing or every other weekesketamine dosing. Number of Changes: 0 = weekly dose throughout OP/MAphase; 1 = 1 change from weekly to every other week (EOW); 2 = changefrom EOW back to weekly; 3 = 2 changes from weekly to EOW remained onEOW; 4 = 2 changes from weekly to EOW and back to weekly; 5 = 3 changesfrom weekly to EOW, remaining on EOW; 6 = 3 changes from weekly to EOWand back to weekly. ^(a) Approximately 22% returned to weekly in total46% on weekly and 16% returned to every other week (in total 54% onevery other week).

Safety Cognition

A primary objective of the study was to assess potential effects ofEsketamine on cognitive function. Potential impact of esketamine oncognition was assessed by the Cogstate Computerized Cognitive Battery.

Number of Subjects Analyzed

-   -   All Enrolled Analysis Set: A total of 796 subjects were        analyzed.    -   Follow-up Analysis Set including only those subjects that were        included in the follow-up phase): A total of 356 subjects were        analyzed.

Timepoints Analyzed

-   -   All Enrolled Analysis Set:        -   Open-label induction phase            -   Baseline            -   Day 28        -   Optimization/Maintenance Phase            -   Week 20            -   Week 32            -   Week 44            -   Endpoint (the last timepoint in the                optimization/maintenance phase subjects performed)    -   Follow-up Analysis Set:        -   Baseline        -   Endpoint (previous phase—the last timepoint in the last            treatment phase subjects participated before entering the            follow-up phase)        -   Week 4

Criteria for Evaluation

-   -   Cogstate Battery        -   Detection Test (DET; to measure attention)        -   Identification Test (IDN; to measure attention)        -   One Card Learning test (OCL; to measure visual learning)        -   One Back Test (ONB; to measure working memory)        -   Groton Maze Learning test (GML; to measure executive            function)

Hopkins Verbal Learning Test-Revised (HVLT-R)

-   -   Total Recall (to measure verbal learning)    -   Delayed Recall (to measure verbal memory)    -   True Positives (to measure recognition memory    -   Recognition Discrimination Index (to measure recognition memory)

In general, group mean performance on the cognition tests assessingattention [detection (DET) and identification (IDN) tests evaluatingsimple and choice reaction times, respectively], visual memory, workingmemory, executive function and delayed verbal memory, and recognitionmemory for the all enrolled analysis set and separately for subjects<65, demonstrated either improvement from baseline or subjects remainedat baseline levels, during both the IND Phase and the OP/MA Phase. Thissame pattern of cognitive performance was also evident for subjects ≥65years of age, except for the tests assessing attention/processing speed(DET and IDN) for which there was a decline from baseline observedstarting at Week 20 with the largest decline at Week 44 of the study.Although sample size decreased at Week 44 in elderly subjects, thedecrease in attention performance in this age group was also apparent incompleter's analysis.

The greatest mean decrease in the speed of performance for DET and IDN(−0.1032 and −0.0587, respectively) observed at week 44 of the study,was smaller as compared to the standard deviation (SD) of themeasurement at baseline (0.15955 and 0.09465, for ATN and IDN,respectively). For reference, the difference observed was lower thandecline in attention seen with 1 mg alprazolam tid. In a previous studyin healthy subjects, the mean group performance decline in attentionparameters of the magnitude of 1 SD following administration of 1 mgalprazolam tid was considered to be clinically significant (Maruff etal. 2006).

Initial evaluation of patient level data shows that 17 of 28 elderlysubjects who completed the study, had persistent decline in attentionmeasures (reliable change index [RCI)<−1.65 for at least 2measurements]. The decline in performance on the detection andidentification tests appears to be consistent in terms of magnitude anddirection across subjects who are 65 to <75 and subjects ≥75 years old,although the sample size for the ≥75 year of age group is very smallsamples and does not allow to draw reliable conclusions about thechange.

Cognitive performance, including performance on attention/reaction timemeasures remained stable during the Follow up period in both elderly andyounger subjects. There was no evidence of the persistent cognitivedecline that has been reported in substance abuse populations usinglarge (often daily) doses of ketamine.

There were 2 subjects who experienced ‘memory impairment’ adverse eventsin the IND phase and 2 subjects in the OP/MA phase. Two subjectsexperienced treatment-emergent ‘cognitive disorder’ during the INDphase. No subjects experienced treatment-emergent ‘cognitive disorder’during the OP/MA phase.

Overall, 723/802 (90.1%) subjects experienced at least one TEAE in theIND and OP/MA phases. The most common (210%) TEAEs during the IND andOP/MA phases were dizziness (33.0%), nausea (25.1%), headache (24.9%),dissociation (22.4%), somnolence (16.7%), dysgeusia and hypoesthesia(11.8% each), vomiting and vertigo (10.8% each), and viral upperrespiratory tract infection (10.2%).

There were 76 (9.5%) subjects who discontinued the IND or OP/MA phaseintranasal study medication due to treatment-emergent adverse events.The most common AEs leading to discontinuation of intranasal studymedication were anxiety (1.1%), suicidal ideation (0.9%), depression,dizziness, and blood pressure increased (0.7% each), dissociation(0.6%), and muscular weakness (0.5%). These subjects could continue theoral AD in the follow-up phase if applicable. There were 33 (4.1%)subjects who discontinued IND or OP/MA phase oral antidepressant studymedication due to treatment-emergent adverse events. The most common AEsleading to discontinuation of oral antidepressant study medication wereanxiety (0.9%) and suicidal ideation (0.6%).

A total of 423 (52.7%) subjects experienced suggestive of potential drugabuse, dependence and withdrawal adverse events during the IND and OP/MAphases.

Transient blood pressure increases for the esketamine+oral AD grouppeaked at 40 minutes post dose with the maximum mean increases (acrossall dosing days in the respective phase) in systolic/diastolic BP being9.6/5.6 mm Hg and 8.6/5.2 mm Hg during the IND and OP/MA phases,respectively. The post dose increases in the systolic and diastolicblood pressure were observed in both study phases. Subjects with andwithout hypertension experienced similar magnitude of mean increases ofSBP and DBP.

Transient changes in systolic and diastolic blood pressures wereobserved throughout the study, consistent with acute esketamine studies.Most subjects who withdrew due to blood pressure elevations, did soafter the first 2 dosing sessions.

The frequency of subjects with treatment-emergent acute hypertension isshown in Table 134B. The incidence of acute hypertension was almost 3×greater in subjects with the history of hypertension vs. subjectswithout hypertension.

TABLE 134B Intranasal Esk + Oral AD (N = 802) Hypertension status: Yes220 Acute hypertension 16 (7.3%) Systolic BP ≥180 10 (4.5%) Diastolic BP≥110 9 (4.1%) Hypertension status: No 580 Acute hypertension 17 (2.9%)Systolic BP ≥180 8 (1.4%) Diastolic BP ≥110 10 (1.7%)

Overall, the dissociative and perceptual change symptoms measured by theCADSS, suggest onset of these symptoms occurred shortly after the startof the dose and resolved at 1.5 hours post dose. These symptomsattenuated with repeated dosing over time. The magnitude of symptomsobserved on the CADSS post dose decreased with repeated doses andcontinued to be low throughout OP/MA phase.

Efficacy: There was a clinically meaningful improvement in depressivesymptoms: the mean change (SD) in MADRS total score from baseline (IND)to end point (IND) was −16.4 (8.76) for esketamine+oral AD with baseline(IND) (SD) of 31.2 (5.27). The mean change (SD) from baseline (OP/MA) toend point (OP/MA) was 0.3 (8.12) for esketamine +oral AD with baseline(OP/MA) (SD) of 11.0 (4.52), indicating that the antidepressant effectis sustained. Similarly, the median change (range) from baseline (IN) toend point (IND) was −18.0 and from baseline (OP/MA) to end point (OP/MA)was 0 for esketamine +oral AD.

The mean change (SD) from Baseline (IND) in PHQ-9 total score to EndPoint (IND) was −8.9 (6.67) for esketamine+oral AD. The mean change (SD)from Baseline (OP/MA) in PHQ-9 total score to End Point (OP/MA) was −0.2(5.65) for esketamine+oral AD.

These results were consistent with MADRS in the direction of changes atthe end of both study phases. Overall efficacy results in the IND phasewere consistent with the results obtained in acute efficacy studies(3001 and 3002). This improvement was corroborated by shifts in theoverall disease severity as assessed by CGI-S: the percentage ofsubjects who were normal/borderline/had mild disease increased from 2.7%at baseline to 63.8% at the end of IND phase. See, FIG. 58.

Tables 134-137 display summaries of mean and mean changes over time forDetection—Attention (simple reaction time) for subjects <65 years and≥65 years of age, respectively.

TABLE 134 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set) Age Group: <65years Base N Mean SD Med Min Max Mean (SD) Detection - Attention (simplereaction time)^(a) Esketamine Baseline (IND) 616 2.5943 0.15532 2.58032.266 3.120 Day 28 (IND) 509 2.5755 0.15174 2.5609 2.214 3.021 2.5930(0.15712) Week 20 (OP/MA) 357 2.5779 0.14060 2.5632 2.250 3.014 2.5903(0.15678) Week 32 (OP/MA) 252 2.5863 0.15081 2.5793 2.253 3.125 2.5971(0.16478) Week 44 (OP/MA) 171 2.5812 0.16642 2.5543 2.252 3.150 2.5780(0.17130) End Point (OP/MA) 449 2.5896 0.14519 2.5820 2.267 3.019 2.5950(0.15654) ^(a)Speed of performance (log10 ms), lower score = betterperformance ^(b) Number of errors, lower score = better performance ^(c)Accuracy of performance, higher score = better performance ^(d) Higherchange from baseline is better performance

TABLE 135 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analvsis Set) Age Group: <65years Change from Baseline^(d) N Mean SE SD Med Min Max Detection -Attention (simple reaction time)^(a) Esketamine Baseline (IND) Day 28(IND) 503 0.0159 0.00525 0.11773 0.0130 −0.499 0.449 Week 20 (OP/MA) 3540.0127 0.00639 0.12023 0.0096 −0.353 0.496 Week 32 (OP/MA) 250 0.01160.00849 0.13430 0.0028 −0.383 0.508 Week 44 (OP/MA) 169 −0.0037 0.009910.12880 −0.0074 −0.517 0.407 End Point (OP/MA) 442 0.0048 0.006000.12610 0.0025 −0.509 0.462 ^(a)Speed of performance (log10 ms), lowerscore = better performance ^(b) Number of errors, lower score = betterperformance ^(c) Accuracy of performance, higher score = betterperformance ^(d)Higher change from baseline is better performance

TABLE 136 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set) Age Group: ≥65years Base N Mean SD Med Min Max Mean (SD) Detection - Attention (simplereaction time)^(a) Esketamine Baseline (IND) 168 2.6133 0.15955 2.57132.321 3.048 Day 28 (IND) 121 2.6018 0.14091 2.5759 2.345 3.065 2.6085(0.14845) Week 20 (OP/MA) 74 2.6331 0.14690 2.6331 2.352 2.968 2.6051(0.14751) Week 32 (OP/MA) 46 2.6539 0.14168 2.6584 2.371 3.067 2.6088(0.14312) Week 44 (OP/MA) 29 2.7083 0.16773 2.7184 2.385 3.082 2.6012(0.16301) End Point (OP/MA) 122 2.6338 0.14625 2.6174 2.364 3.068 2.6009(0.15025) ^(a)Speed of performance (log₁₀ ms), lower score = betterperformance ^(b) Number of errors, lower score = better performance ^(c)Accuracy of performance, higher score = better performance ^(d) Higherchange from baseline is better performance

TABLE 137 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set) Age Group: ≥65years Change from Baseline^(d) N Mean SE SD Med Min Max Detection -Attention (simple reaction time)^(a) Esketamine Baseline (IND) Day 28(IND) 120 0.0076 0.01267 0.13876 0.0071 −0.438 0.431 Week 20 (OP/MA) 72−0.0258 0.01684 0.14292 −0.0152 −0.374 0.496 Week 32 (OP/MA) 45 −0.04270.02635 0.17679 −0.0496 −0.529 0.449 Week 44 (OP/MA) 28 −0.1032 0.030670.16230 −0.0914 −0.544 0.129 End Point (OP/MA) 119 −0.0313 0.011820.12889 −0.0379 −0.352 0.384 ^(a)Speed of performance (log₁₀ ms), lowerscore = better performance ^(b) Number of errors, lower score = betterperformance ^(c) Accuracy of performance, higher score = betterperformance ^(d)Higher change from baseline is better performance

Tables 138-141 display summaries of mean and mean changes over time forIdentification—Attention (choice reaction time) for subjects <65 yearsand ≥65 years of age, respectively. See, also, FIG. 59.

TABLE 138 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set) Age Group: <65years Base N Mean SD Med Min Max Mean (SD) Identification- Attention(choice reaction time)^(a) Esketamine Baseline (IND) 616 2.7506 0.112722.7386 2.506 3.167 Day 28 (IND) 515 2.7381 0.09859 2.7332 2.479 3.1012.7504 (0.11222) Week 20 (OP/MA) 361 2.7438 0.09864 2.7437 2.510 3.0682.7466 (0.10801) Week 32 (OP/MA) 252 2.7476 0.10479 2.7320 2.509 3.1492.7539 (0.11351) Week 44 (OP/MA) 170 2.7471 0.11037 2.7289 2.532 3.1562.7508 (0.11555) End Point (OP/MA) 449 2.7557 0.09838 2.7510 2.482 3.1002.7506 (0.11105) ^(a)Speed of performance (log₁₀ ms), lower score =better performance ^(b) Number of errors, lower score = betterperformance ^(c) Accuracy of performance, higher score = betterperformance ^(d) Higher change from baseline is better performance

TABLE 139 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set) Age Group: <65years Change from Baseline^(d) N Mean SE SD Med Min Max Identification-Attention (choice reaction time)^(a) Esketamine Baseline (IND) Day 28(IND) 509 0.0125 0.00389 0.08785 0.0102 −0.297 0.463 Week 20 (OP/MA) 3580.0026 0.00475 0.08983 0.0004 −0.372 0.358 Week 32 (OP/MA) 251 0.00620.00684 0.10842 0.0084 −0.496 0.379 Week 44 (OP/MA) 169 0.0034 0.008330.10828 −0.0034 −0.392 0.383 End Point (OP/MA) 442 −0.0050 0.004850.10198 −0.0084 −0.370 0.441 ^(a)Speed of performance (log₁₀ ms), lowerscore = better performance ^(b) Number of errors, lower score = betterperformance ^(c) Accuracy of performance, higher score = betterperformance ^(d)Higher change from baseline is better performance

TABLE 140 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set); Age Group: ≥65years Base N Mean SD Med Min Max Mean (SD) Identification- Attention(choice reaction time)^(a) Esketamine Baseline (IND) 168 2.7498 0.094652.7302 2.564 3.085 Day 28 (IND) 122 2.7505 0.09061 2.7295 2.609 3.1112.7491 (0.08531) Week 20 (OP/MA) 74 2.7570 0.08077 2.7544 2.606 3.0292.7416 (0.08251) Week 32 (OP/MA) 47 2.7683 0.10237 2.7551 2.618 3.1312.7453 (0.08426) Week 44 (OP/MA) 29 2.7917 0.12868 2.7583 2.567 3.1512.7294 (0.08842) End Point (OP/MA) 122 2.7673 0.09180 2.7675 2.583 3.0432.7455 (0.09022) ^(a)Speed of performance (log₁₀ ms), lower score =better performance ^(b) Number of errors, lower score = betterperformance ^(c) Accuracy of performance, higher score = betterperformance ^(d) Higher change from baseline is better performance

TABLE 141 Cognitive Domains: Means and Mean Changes from Baseline (IND)Over Time by Age; Open-label Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set); Age Group: ≥65years Cange from Baseline^(d) N Mean SE SD Med Min Max Identification-Attention (choice reaction time)^(a) Esketamine Baseline (IND) Day 28(IND) 121 −0.0001 0.00743 0.08175 −0.0014 −0.332 0.307 Week 20 (OP/MA)72 −0.0136 0.00918 0.07794 −0.0058 −0.294 0.252 Week 32 (OP/MA) 46−0.0210 0.01483 0.10060 −0.0226 −0.415 0.257 Week 44 (OP/MA) 28 −0.05870.01955 0.10346 −0.0391 −0.435 0.122 End Point (OP/MA) 119 −0.02030.00661 0.07206 −0.0216 −0.209 0.241 ^(a)Speed of performance (log₁₀ms), lower score = better performance ^(b) Number of errors, lower score= better performance ^(c) Accuracy of performance, higher score = betterperformance ^(d)Higher change from baseline is better performance

There were 2 subjects who experienced ‘memory impairment’ in the INDphase and 2 subjects in the OP/MA phase. Two subjects experiencedtreatment-emergent ‘cognitive disorder’ during the IND phase. Nosubjects experienced treatment-emergent ‘cognitive disorder’ during theOP/MIA phase.

Overall, predose cognitive assessments showed general preservation orimprovement in cognition from baseline in subjects <65 years of age.Cognitive data in subjects a 65 years old also showed preservation orimprovement in most of the domains tested, but relatively smallperformance decrements in two measures of attention were observed. Thesubject level data underlying these apparent changes are being furtherevaluated to assess the extent to which they may be clinicallymeaningful in some individuals.

Summary of All Adverse Events

An overall summary of all treatment-emergent adverse events (TEAEs)during the IND and OP/MA phases is presented in Table 142. Overall,90.1% of subjects experienced at least one TEAE in the IND and OP/MAphases.

TABLE 142 Overall Summary of Treatment-emergent Adverse Events;Induction and Optimization/Maintenance Phases (Study ESKETINTRD3004: AllEnrolled Analysis Set) Intranasal Esk + Oral AD (N = 802) TEAE 723(90.1%) TEAE possibly related to intranasal drug ^(a) 633 (78.9%) TEAEpossibly related to oral antidepressant ^(a) 241 (30.0%) TEAE leading todeath  2 (0.2%) 1 or more serious TEAE 55 (6.9%) TEAE leading tointranasal drug withdrawn ^(b) 76 (9.5%) TEAE leading to oralantidepressant withdrawn ^(b) 33 (4.1%) ^(a) Study drug relationships ofpossible, probable, and very likely are included in this category. ^(b)An adverse event that started in the induction oroptimization/maintenance phase and resulted in discontinuation in thefollow-up phase is counted as treatment-emergent in this table.Incidence is based on the number of subjects experiencing at least oneadverse event, not the number of events. Adverse events are coded usingMedDRA version 20.0.

Treatment-emergent adverse events occurring during the IND and OP/MAphases (>5% of subjects) are summarized for the all enrolled analysisset in Tables 143A and 143B. The most common (≥10%) TEAEs during the INDand OP/MA phases were dizziness (33.0%), nausea (25.1%), headache(24.9%), dissociation (22.4%), somnolence (16.7%), dysgeusia andhypoesthesia (11.8% each), vomiting and vertigo (10.8% each), and viralupper respiratory tract infection (10.2%). The incidence of nausea washighest on Day 1 dosing (10.7%) and decreased on subsequent dosing daysranging from 0.0 to 4.4%. The incidence of vomiting was highest on Day 1dosing (3.3%) and decreased on subsequent dosing days ranging from 0.0%to 1.9%.

TABLE 143A Adverse Events in at Least 5% of Subjects; Induction andOptimization/Maintenance Phases (Study ESKETINTRD3004: All EnrolledAnalysis Set) Intranasal Esk + Oral AD (N = 802) Total no. subjects withAE 723 (90.1%) Nervous system disorders 528 (65.8%) Dizziness 265(33.0%) Headache 200 (24.9%) Somnolence 134 (16.7%) Dysgeusia 95 (11.8%)Hypoesthesia 95 (11.8%) Sedation 71 (8.9%) Dizziness postural 67 (8.4%)Paresthesia 58 (7.2%) Gastrointestinal disorders 375 (46.8%) Nausea 201(25.1%) Vomiting 87 (10.8%) Hypoesthesia oral 73 (9.1%) Diarrhea 60(7.5%) Psychiatric disorders 368 (45.9%) Dissociation 180 (22.4%)Anxiety 72 (9.0%) Insomnia 64 (8.0%) Infections and infestations 279(34.8%) Viral upper respiratory tract infection 82 (10.2%) Urinary tractinfection 65 (8.1%) Influenza 43 (5.4%) General disorders andadministration site 201 (25.1%) conditions Feeling abnormal 67 (8.4%)Fatigue 63 (7.9%) Musculoskeletal and connective tissue 156 (19.5%)disorders Back pain 41 (5.1%) Investigations 140 (17.5%) Blood pressureincreased 73 (9.1%) Ear and labyrinth disorders 125 (15.6%) Vertigo 87(10.8%) Eye disorders 106 (13.2%) Vision blurred 59 (7.4%) Incidence isbased on the number of subjects experiencing at least one adverse event,not the number of events. Adverse events are coded using MedDRA version20.0.

TABLE 143B Treatment-emergent adverse events(full analysis sets [IND andOP/MAINT] and all enrolled analysis set) 48-week OP/ IND and OP/ 4-weekIND phase MAINT phase MAINT phases (N = 779) (N = 603) (N = 802) n (%) n(%) n (%) Patients with ≥1 TEAEs 653 (83.8) 516 (85.6) 723 (90.1)Patients with ≥1 SAEs 17 (2.2) 38 (6.3) 55 (6.9) TEAEs leading to 53(6.8) 23 (3.8) 76 (9.5) discontinuation of intranasal spray medicationTEAEs leading to 20 (2.6) 14 (2.3) 33 (4.1) discontinuation of oral ADTEAEs leading to death 0 2 (0.3) 2 (0.2) Most common TEAEs (≥10%patients in the combined phases group) Dizziness 228 (29.3) 135 (22.4)264 (32.9) Dissociation 180 (23.1) 112 (18.6) 220 (27.4) Nausea 157(20.2) 84 (13.9) 201 (25.1) Headache 137 (17.6) 114 (18.9) 200 (24.9)Somnolence 94 (12.1) 85 (14.1) 134 (16.7) Dysgeusia 77 (9.9) 54 (9.0) 95(11.8) Hypoesthesia 79 (10.1) 40 (6.6) 95 (11.8) Vertigo 68 (8.7) 43(7.1) 88 (11.0) Vomiting 56 (7.2) 45 (7.5) 87 (10.8) Viral upperrespiratory tract 19 (2.4) 70 (11.6) 82 (10.2) infection Increased bloodpressure- related TEAEs Increased blood pressure 53 (6.8) 46 (7.6) 75(9.4) Hypertension 13 (1.7) 13 (2.2) 25 (3.1) Increased heart rate-related TEAEs Tachycardia 6 (0.8) 8 (1.3) 13 (1.6) Cystitis-relatedTEAEs Cystitis 4 (0.5) 1 (0.2) 5 (0.6)

FIGS. 60-62 show the level of impairment for the EQ-5D-5L by measuringanxiety/depression, usual activities, and pain/discomfort, respectively.Scores ranged from levels 1-5: 1 (none), s (slight), 3 (moderate), 4(Severe), and 5 (Extreme).

Serious Adverse Events

Two deaths were reported during the OP/MA phase of the study.

One 60-year old male with a medical history of hypertension and veinsurgery, experienced death due to acute cardiac and respiratory failureon Day 113 of the treatment with esketamine which were considereddoubtfully related to esketamine. This subject did not experience anyprior cardiac adverse events during treatment with esketamine and oralAD and had normal blood pressures during the study. The subject had beenreceiving esketamine 56 mg, with the last dose administered 5 days priorto the death.

One 55-year old female died as a result of suicide on Day 188 of thestudy. This subject manifested remission of depressive symptoms asevidenced by MADRS score of 7 and 9 measured at the last 2 clinicvisits, 13 days and 6 days prior to the event, respectively. The eventwas considered not related to esketamine. The subject had been receivingesketamine 84 mg, with the last dose administered 13 days prior to thedeath.

A total of 55 (6.9%) subjects experienced a total of 68 serioustreatment-emergent adverse event during the IND and OP/MA phases for theall enrolled analysis set. Four subjects had serious TEAE assessed asrelated (possibly, probably or very likely) to intranasal esketamine bythe investigators: delirium, anxiety and delusion, suicidal ideation andsuicidal attempt. The following SAEs led to discontinuation ofesketamine treatment: 5 cases of suicidal ideation; 2 cases each ofsuicidal attempts, depression, anxiety, and toxicity to various agents(listed as “zolpidem and oxazepam intoxication” in one participant, and;“drug intoxication” in the other); and 1 event of each of the following:alcohol abuse, depression suicidal (depression with suicidal thoughts),delusions, delirium and hepatitis B.

The SAE of delirium was reported on Day 127 in a subject who remained onalcohol abuse prevention treatment throughout the study (though had nocurrent abuse), within minutes after dosing with 56 mg of esketamine.The SAE was assessed as very likely related to ESK, and not related tothe oral AD. During the event the subject had a period of agitation withrandom limb movements followed by 10 min period of non-responsiveness tostimuli. This subject tolerated esketamine well prior to this event. Nodrug or alcohol test was done during that visit. Subject washospitalized, withdrawn from the study and recovered from the event in18 days. CT scan, MRI and EEG were all normal. The exact cause ofdelirium remains unknown, the use of other substances cannot beexcluded.

The SAEs of anxiety and delusions were reported prior to dosing with ESKon Day together with SAE of alcohol abuse (which was assessed as notrelated to esketamine in the opinion of the Investigator). This subjecthad no history of psychosis or delusions and negative alcohol screeningtests. Subsequently, the subject disclosed excessive alcoholconsumption. Subject was hospitalized and withdrawn from the study.

The SAEs related to renal function included pyelonephritis, acutepyelonephritis and 1 case of tubulointerstitial nephritis. All theseSAEs resolved after appropriate treatment without sequalae and subjectscontinued in the study.

Three subjects had a serious TEAEs that were considered related to oralantidepressant by the investigators: gastroenteritis, colitismicroscopic, and suicidal ideation. See, Tables 144A and 1448.

TABLE 144A Treatment-emergent Serious Adverse Events; Induction andOptimization/Maintenance Phases (Study ESKETINTRD3004: All EnrolledAnalysis Set) Intranasal Esk + Oral AD (N = 802) Total no. subjects witha serious TEAE 55 (6.9%)  Psychiatric disorders 26 (3.2%)  Depression 8(1.0%) Suicidal ideation 6 (0.7%) Suicide attempt 6 (0.7%) Anxiety 2(0.2%) Alcohol abuse 1 (0.1%) Completed suicide 1 (0.1%) Delirium 1(0.1%) Delusion 1 (0.1%) Depression suicidal 1 (0.1%) Intentionalself-injury 1 (0.1%) Major depression 1 (0.1%) Infections andinfestations 8 (1.0%) Gastroenteritis 2 (0.2%) Bronchitis 1 (0.1%)Dengue fever 1 (0.1%) Hepatitis B 1 (0.1%) Pyelonephritis 1 (0.1%)Pyelonephritis acute 1 (0.1%) Urinary tract infection 1 (0.1%)Gastrointestinal disorders 6 (0.7%) Anal incontinence 1 (0.1%) Colitismicroscopic 1 (0.1%) Hemorrhoids 1 (0.1%) Large intestinal obstruction 1(0.1%) Oesophageal ulcer 1 (0.1%) Pancreatitis 1 (0.1%) Injury,poisoning and procedural complications 6 (0.7%) Toxicity to variousagents 2 (0.2%) Costochondral separation 1 (0.1%) Fibula fracture 1(0.1%) Foot fracture 1 (0.1%) Poisoning 1 (0.1%) Musculoskeletal andconnective tissue disorders 4 (0.5%) Arthralgia 1 (0.1%) Back pain 1(0.1%) Osteoarthritis 1 (0.1%) Synovial cyst 1 (0.1%) Nervous systemdisorders 2 (0.2%) Headache 1 (0.1%) Psychomotor hyperactivity 1 (0.1%)Renal and urinary disorders 2 (0.2%) Stress urinary incontinence 1(0.1%) Tubulointerstitial nephritis 1 (0.1%) Vesical fistula 1 (0.1%)Cardiac disorders 1 (0.1%) Cardiac failure acute 1 (0.1%) Generaldisorders and administration site 1 (0.1%) conditions Pyrexia 1 (0.1%)Investigations 1 (0.1%) Transaminases increased 1 (0.1%) Neoplasmsbenign, malignant and unspecified 1 (0.1%) (incl cysts and polyps)Ovarian cancer 1 (0.1%) Pregnancy, puerperium and perinatal conditions 1(0.1%) Abortion spontaneous 1 (0.1%) Reproductive system and breastdisorders 1 (0.1%) Menorrhagia 1 (0.1%) Respiratory, thoracic andmediastinal disorders 1 (0.1%) Acute respiratory failure 1 (0.1%)Incidence is based on the number of subjects experiencing at least oneadverse event, not the number of events. Adverse events are coded usingMedDRA version 20.0.

TABLE 144B Most Common Serious Adverse Events in at least 2 patients inthe combined phases (full analysis sets [IND and OP/MAINT] and allenrolled analysis set) IND and OP/ Most common IND phase OP/MAINT phaseMAINT phases SAEs (≥2 (N = 779) (N = 604) (N = 802) patients) n (%) n(%) n (%) Depression 5 (0.6) 3 (0.5) 8 (1.0) Suicidal ideation 2 (0.3) 4(0.7) 6 (0.7) Suicide attempt 4 (0.5) 2 (0.3) 6 (0.7) Anxiety 2 (0.3) 02 (0.2) Gastroenteritis 0 2 (0.3)

The event of suicidal ideation (moderate intensity) started on Day 207of the study and led to discontinuation. The same subject was alsoreported with akathisia on Day 206 (mild). Subject recovered fromsuicidal ideation within 30 days.

Adverse Events Leading to Study Drug Withdrawal

The number of treatment-emergent adverse events (TEAEs) leading todiscontinuation of study treatment was low for of this study and TRDpatient population. Most of the discontinuations due to AE'S during theIND phase were after the initial ESK treatment sessions.

There were 76 (9.5%) subjects who discontinued the IND or OP/MA phaseintranasal study medication due to treatment-emergent adverse events(Tables 145A and 145B). A total of 53/779 (6.8%) subjects discontinuedintranasal study medication in the IND phase and 23/603 (3.8%) subjectsdiscontinued intranasal study medication in the OP/MA phase due totreatment-emergent adverse events. This is much lower than other drugsused for TRD, e.g. 23.7% rate in a quetiapine 52-week safety study inMDD/TRD subjects (Berman et al., 2011) and a 24.5% over 76 weeks treatedwith Symbyax in MDD/TRD subjects (Corya, Long-term antidepressantefficacy and safety of olanzapine/fluoxetine combination: a 76-weekopen-label study. Journal of Clinical Psychiatry: 64 (11) p. 1349-56.2003).

The most common AEs leading to discontinuation of intranasal studymedication were anxiety (1.1%), suicidal ideation (0.9%), depression,dizziness, and blood pressure increased (0.7% each), dissociation(0.6%), and muscular weakness (0.5%). These subjects could continue theoral AD in the follow-up phase if applicable. There were 33 (4.1%)subjects who discontinued the IND or OP/MA phase oral antidepressantstudy medication due to treatment-emergent adverse events (Table 146). Atotal of 20/779 (2.6%) subjects discontinued oral antidepressant in theIND phase and 14/603 (2.3%) discontinued oral antidepressant studymedication in the OP/MA phase due to treatment-emergent adverse events.One subject discontinued one oral antidepressant during the IND phaseand switched to another oral antidepressant. The most common AEs leadingto discontinuation of oral antidepressant study medication were anxiety(0.9%) and suicidal ideation (0.6%). Twenty-six subjects discontinuedthe IND or OP/MA phase due to adverse events related to both intranasaland oral AD medications and are included in both tables.

One subject was diagnosed with the SAEs of severe hepatitis B andmoderate ovarian cancer were considered not related to ESK by theinvestigator). This subject had clinically significant elevations in theliver function tests, suspected initially to be a manifestation ofdrug-induced liver injury. This subject however responded withlaboratory and clinical improvement to initiated antiviral treatmentwhich, together with positive hepatitis serology, confirmed thediagnosis of hepatitis B.

Among the 76 subjects with TEAEs leading to discontinuation ofintranasal esketamine during the IND or OP/MA phases, 51 subjects had anAE that was considered related (possibly, probably, or very likely) toesketamine. Among the 33 subjects with TEAEs leading to discontinuationof oral AD during the IND or OP/MA phases, 14 subjects had an AE thatwas considered related to oral AD.

Nine subjects discontinued due to blood pressure increase orhypertension. Six of these subjects discontinued early in the IND phase(on Day 1, 2, 4, 4, 8 and 9 of the study). Four of these subjects metwithdrawal criteria for elevated blood pressure (SBP≥200 mm Hg and/orDBP; 120 mm Hg for subjects <65 years old and SBP≥190 and DBP≥110).

A total of 7 subjects had suicidal ideation and 2 attempted suicideduring the IND or OP/MA phases that led to study drug withdrawal ofesketamine. In one suicide attempt, a 46-year old female subject on Day44 overdosed on medication and was intoxicated with carbon monoxide.This SAE was assessed as life-threatening, probably related toesketamine and not related to oral antidepressant. The subject was aresponder, however had chronic and acute life stressors. Subjectrecovered from the event within 11 days.

TABLE 145A Treatment-emergent Adverse Events Leading to Discontinuationof Intranasal Study Medication; Induction and Optimization/MaintenancePhases (Study ESKETINTRD3004: All Enrolled Analysis Set) IntranasalEsk + Oral AD (N = 802) Total no. subjects with TEAE leading to 76(9.5%)  discontinuation ^(a) Psychiatric disorders 32 (4.0%)  Anxiety 9(1.1%) Suicidal ideation 7 (0.9%) Depression 6 (0.7%) Dissociation 5(0.6%) Suicide attempt 2 (0.2%) Alcohol abuse 1 (0.1%) Delirium 1 (0.1%)Delusion 1 (0.1%) Depression suicidal 1 (0.1%) Hallucination, auditory 1(0.1%) Major depression 1 (0.1%) Panic attack 1 (0.1%) Paranoia 1 (0.1%)Psychogenic tremor 1 (0.1%) Nervous system disorders 13 (1.6%) Dizziness 6 (0.7%) Headache 2 (0.2%) Sedation 2 (0.2%) Somnolence 2(0.2%) Cognitive disorder 1 (0.1%) Depressed level of consciousness 1(0.1%) Generalized tonic-clonic seizure 1 (0.1%) Psychomotorhyperactivity 1 (0.1%) Reduced facial expression 1 (0.1%) Investigations7 (0.9%) Blood pressure increased 6 (0.7%) Electrocardiogram QTprolonged 1 (0.1%) Musculoskeletal and connective tissue disorders 7(0.9%) Muscular weakness 4 (0.5%) Muscle rigidity 1 (0.1%) Myalgia 1(0.1%) Pain in extremity 1 (0.1%) Gastrointestinal disorders 6 (0.7%)Vomiting 3 (0.4%) Nausea 2 (0.2%) Abdominal discomfort 1 (0.1%)Abdominal pain 1 (0.1%) General disorders and administration site 4(0.5%) conditions Asthenia 1 (0.1%) Feeling drunk 1 (0.1%) Malaise 1(0.1%) Therapeutic response changed 1 (0.1%) Cardiac disorders 3 (0.4%)Angina pectoris 1 (0.1%) Arrhythmia 1 (0.1%) Coronary artery disease 1(0.1%) Ventricular arrhythmia 1 (0.1%) Eye disorders 3 (0.4%)Blepharitis 1 (0.1%) Vision blurred 1 (0.1%) Vitreous detachment 1(0.1%) Injury, poisoning and procedural complications 3 (0.4%) Toxicityto various agents 2 (0.2%) Fall 1 (0.1%) Vascular disorders 3 (0.4%)Hypertension 3 (0.4%) Ear and labyrinth disorders 2 (0.2%) Vertigo 2(0.2%) Deafness bilateral 1 (0.1%) Metabolism and nutrition disorders 2(0.2%) Failure to thrive 1 (0.1%) Hyperglycemia 1 (0.1%) Infections andinfestations 1 (0.1%) Hepatitis B 1 (0.1%) Renal and urinary disorders 1(0.1%) Urinary incontinence 1 (0.1%) Respiratory, thoracic andmediastinal disorders 1 (0.1%) Asthma 1 (0.1%) Oropharyngeal pain 1(0.1%) Skin and subcutaneous tissue disorders 1 (0.1%) Eczema 1 (0.1%)^(a) An adverse event that started in the induction oroptimization/maintenance phases and resulted in discontinuation in thefollow-up phase is counted as treatment-emergent in this table.Incidence is based on the number of subjects experiencing at least oneadverse event, not the number of events. Adverse events are coded usingMedDRA version 20.0.

TABLE 145B Treatment-emergent Adverse Events Leading to Discontinuationof Intranasal Study Medication in at least 2 Patients in the CombinedPhases (IND and OP/MAINT and All Enrolled Analysis Set) IND and OP/ Mostcommon IND phase OP/MAINT phase MAINT phases TEAEs (≥2 (N = 779) (N =603) (N = 802) patients) n (%) n (%) n (%) Anxiety 9 (1.2) 0 9 (1.1%)Suicidal ideation 3 (0.4) 4 (0.7) 7 (0.9%) Depression 3 (0.4) 3 (0.5) 6(0.7%) Dizziness 6 (0.8) 0 6 (0.7%) Blood pressure increased 4 (0.5) 2(0.3) 6 (0.7%) Dissociation 5 (0.6) 0 5 (0.6%) Muscular weakness 4 (0.5)0 4 (0.5%) Vomiting 3 (0.4) 0 3 (0.4%) Hypertension 2 (0.3) 1 (0.2) 3(0.4%) Suicide attempt 1 (0.1) 1 (0.2) 2 (0.2%) Headache 2 (0.3) 0 2(0.2%) Sedation 2 (0.3) 0 2 (0.2%) Somnolence 2 (0.3) 0 2 (0.2%) Nausea2 (0.3) 0 2 (0.2%) Vertigo 1 (0.1) 1 (0.2) 2 (0.2%)

TABLE 146 Treatment-emergent Adverse Events Leading to Discontinuationof Oral Antidepressant; Induction or Optimization/Maintenance Phases(Study ESKETINTRD3004: All Enrolled Analysis Set) Intranasal Esk + OralAD (N = 802) Total no. subjects with TEAE leading to 33 (4.1%) discontinuation ^(a) Psychiatric disorders 20 (2.5%)  Anxiety 7 (0.9%)Suicidal ideation 5 (0.6%) Depression 3 (0.4%) Suicide attempt 2 (0.2%)Alcohol abuse 1 (0.1%) Anorgasmia 1 (0.1%) Delirium 1 (0.1%) Delusion 1(0.1%) Dissociation 1 (0.1%) Insomnia 1 (0.1%) Gastrointestinaldisorders 5 (0.6%) Abdominal discomfort 1 (0.1%) Abdominal pain 1 (0.1%)Colitis microscopic 1 (0.1%) Dry mouth 1 (0.1%) Nausea 1 (0.1%) Nervoussystem disorders 3 (0.4%) Dizziness 1 (0.1%) Headache 1 (0.1%) Reducedfacial expression 1 (0.1%) Somnolence 1 (0.1%) Injury, poisoning andprocedural complications 2 (0.2%) Fall 1 (0.1%) Toxicity to variousagents 1 (0.1%) Musculoskeletal and connective tissue disorders 2 (0.2%)Muscle rigidity 1 (0.1%) Myalgia 1 (0.1%) Vascular disorders 2 (0.2%)Hot flush 1 (0.1%) Hypertension 1 (0.1%) Cardiac disorders 1 (0.1%)Ventricular arrhythmia 1 (0.1%) Ear and labyrinth disorders 1 (0.1%)Deafness bilateral 1 (0.1%) Vertigo 1 (0.1%) General disorders andadministration site 1 (0.1%) conditions Therapeutic response changed 1(0.1%) Infections and infestations 1 (0.1%) Hepatitis B 1 (0.1%)Investigations 1 (0.1%) Blood pressure increased 1 (0.1%) Metabolism andnutrition disorders 1 (0.1%) Failure to thrive 1 (0.1%) Renal andurinary disorders 1 (0.1%) Urinary incontinence 1 (0.1%) Reproductivesystem and breast disorders 1 (0.1%) Erectile dysfunction 1 (0.1%)Respiratory, thoracic and mediastinal disorders 1 (0.1%) Asthma 1 (0.1%)Oropharyngeal pain 1 (0.1%) ^(a) An adverse event that started in theinduction or optimization/maintenance phases and resulted indiscontinuation in the follow-up phase is counted as treatment-emergentin this table. Incidence is based on the number of subjects experiencingat least one adverse event, not the number of events. Adverse events arecoded using MedDRA version 20.0.

Cystitis, Urinary Tract Infections and Other Renal and Urinary Disorders

There were no cases of interstitial cystitis or ulcerative cystitis.Five (0.6%) subjects experienced a treatment-emergent cystitis duringthe IND and OP/MA phases. Three subjects experienced mild cystitis withdurations of 2, 4, and 9 days and one subject experienced moderatecystitis for 7 days during the IND phase. One subject experienced mildcystitis for 7 days in the OP/MA phase. There were no dose changes ordiscontinuations to either intranasal esketamine or oral antidepressantfor these events. See, Table 147.

TABLE 147 Treatment-emergent Cystitis Adverse Events; Induction andOptimization/Maintenances Phase (Study ESKETINTRD3004: All EnrolledAnalysis Set) Intranasal Esk + Oral AD (N = 802) Total no. subjects withTEAE 5 (0.6%) Infections and infestations 5 (0.6%) Cystitis 5 (0.6%)Incidence is based on the number of subjects experiencing at least oneadverse event, not the number of events. Adverse events are coded usingMedDRA version 20.0.

A total of 65 subjects (8.1%) experienced urinary tract infections and84 subjects (10.5%) experienced renal and urinary disorders during theIND and OP/MA phases.

The TEAEs of cystitis were mostly of mild severity, mostly reported inthe IND phase (Days 13, 15, 20, 40 and 78), transient and self-limiting,pointing towards an infectious etiology of UTI cases. Four subjectsreported urinary incontinence assessed as ESK-related (i.e. possibly,probably or very likely related)

Drug Abuse, Dependence and Withdrawal Adverse Events

Drug abuse, dependence and withdrawal adverse events during the IND andOP/MA phases are presented in Table 148. A total of 423 (52.7%) subjectsexperienced drug abuse, dependence and withdrawal during the IND andOP/MA phases.

TABLE 148 Treatment-emergent Drug Abuse, Dependence, and WithdrawalAdverse Events; Induction and Optimization/Maintenance Phases (StudyESKETINTRD3004: All Enrolled Analysis Set) Intranasal Esk + Oral AD (N =802) Total no. subjects with TEAE 423 (52.7%) Nervous system disorders320 (39.9%) Dizziness 265 (33.0%) Somnolence 134 (16.7%) Mentalimpairment 4 (0.5%) Psychomotor hyperactivity 2 (0.2%) Psychiatricdisorders 209 (26.1%) Dissociation 180 (22.4%) Euphoric mood 24 (3.0%)Confusional state 14 (1.7%) Hallucination, visual 10 (1.2%)Disorientation 6 (0.7%) Thinking abnormal 5 (0.6%) Inappropriate affect4 (0.5%) Hallucination, auditory 3 (0.4%) Hallucination 2 (0.2%) Generaldisorders and administration site 77 (9.6%) conditions Feeling abnormal67 (8.4%) Feeling drunk 12 (1.5%) Feeling of relaxation 5 (0.6%)Incidence is based on the number of subjects experiencing at least oneadverse event, not the number of events; Adverse events are coded usingMedDRA version 20.0.

Vital Signs and Body Weight

FIGS. 63 and 64 present means for blood pressure over time during theIND and OP/MA phases.

Transient blood pressure increases for the esketamine+oral AD grouppeaked at 40 minutes past dose with the maximum mean increases (acrossall dosing days within the respective phase) in systolic BP being 9.6and 8.6 during the IND and OP/MA phases, respectively. The maximum meanincreases (across all dosing days within the respective phase) indiastolic BP were 5.6 and 5.2 in the IND and OP/MA phases, respectively.

A total of 18 subjects experienced systolic blood pressure ≥180 and 18experienced diastolic blood pressure ≥110 at any time during the IND andOP/MA phases.

Six subjects discontinued intranasal esketamine due to increased bloodpressure and 1 subject discontinued oral AD due to increased bloodpressure. These subjects could have continued the oral AD during thefollow-up phase if applicable.

The mean body weight at baseline of the IND phase was 78.53 kg and onDay 28 of the IND phase was 78.24 kg. The mean body weight at baselineof the OP/MA phase was 79.01 kg and at the endpoint was 79.16 kg.

Overall, nasal tolerability was favorable, as evidenced by the resultsof nasal examination performed by the investigator before dosing andnasal safety questionnaire completed by subjects predose and 1 hour postdose.

No apparent, clinically significant, drug-related changes from baselinein the mean laboratory hematology and/or biochemistry parameters wereobserved during the IND and OP/MA phase. Asymptomatic increases inALT >3×ULN (upper limit of normal) were reported in 13 subjects (1.6%),most of which occurred in the first 1-3 months of treatment. Theseincreases normalized while treatment was ongoing in most subjects. Nopersistent increases in ALT were observed. One case of suspected DILIwas reported with ALT/AST >5× and bilirubin >2×uln elevation, wherealternative etiology (hepatitis B) was found.

Other Safety Observations Clinician-Assessed Dissociative Symptom Scale(CADSS)

The Clinician Administered Dissociative States Scale (CADSS) wasmeasured prior to the start of each dose, at 40 minutes, and 1.5 hourspostdose. The CADSS is used to assess treatment emergent dissociativesymptoms and perceptual changes and the total score ranges from 0 to 92with a higher score representing a more severe condition.

The dissociative and perceptual change symptoms measured by the CADSS,suggest these symptoms had an onset shortly after the start of the doseand resolved by 1.5 hours postdose (FIG. 65). The greatest increase inCADSS score at 40 minutes was observed after the first esketamine dosein the induction phase.

Modified Observer's Assessment of Alertness/Sedation (MOAA/S)

MOAA/S was used to measure treatment-emergent sedation with correlationto levels of sedation defined by the American Society ofAnesthesiologists (ASA) continuum. The MOAA/S scores range from 0 (Noresponse to painful stimulus; corresponds to ASA continuum for generalanesthesia) to 5 (Readily responds to name spoken in normal tone[awake]; corresponds to ASA continuum for minimal sedation).

There were 65/777 (8.4%) subjects with MOAA/S score ≤3 at any timeduring the IND phase and 42/603 (7.0%) subjects with MOAA/S≤3 at anytime during the OP/MA phase.

Two subjects experienced deep sedation equivalent to MOAA/S score of 0at one of the study visits. In one of these subjects, a decrease inMOAA/S score on Day 8 (IND) was reported as an adverse event of sedationof moderate intensity, with a duration of 1 hour 30 minutes. The subjectdiscontinued Esketamine due to nausea and GI discomfort occurring on thesame day. Another subject was reported with an AE of ‘unresponsive tostimuli’ on Day 15 (IND) of severe intensity and the dose of esketaminewas reduced from 84 mg to 56 mg.

In addition, 3 subjects experienced a transient decrease of MOAA/S tothe score of 1 at one visit and single timepoint post dose (Day 4 (IND),Day 11 (IND) and Week 10 (OP/MA)).

No subject in the study required cardiovascular resuscitation. Subjectswith MOAA/S of 0 had normal pulse oximetry and no decreases in the bloodpressure or respiratory rate. Overall respiratory rate and pulseoximetry after ESK administration remained stable during both IND andOP/MA phase. Although individual subjects showed decreases in pulseoximetry <93% these decreases were asymptomatic, subjects remained alertand no case of respiratory depression was observed.

Brief Psychiatric Rating Positive Symptom Subscale (BPRS+)

FIG. 66 is a plot showing the mean (t) SE for the of the briefpsychiatric rating positive symptom subscale total score over timeduring the induction and optimization/maintenance phases (all enrolledanalysis set) for Example 5.

Efficacy Analyses

The efficacy analyses were performed on the full analysis sets for theIND and OP/MA phases including all enrolled subjects who received atleast 1 dose of intranasal study medication or 1 dose of oralantidepressant study medication in the respective phases.

Montgomery-Asberg Depression Rating Scale (MADRS)

The MADRS consists of 10 items each scored from 0 (symptom is notpresent or is normal) to 6 (severe or continuous presence of thesymptom). A total score (0 to 60) is calculated by summing the scores ofall 10 items. A higher score represents a more severe condition.

The mean change (SD) from Baseline (IND) in MADRS total score to EndPoint (IND) was −16.4 (8.76) for esketamine+oral AD. The mean change(SD) from Baseline (OP/MA) in MADRS total score to End Point (OP/MA) was0.3 (8.12) for esketamine+oral AD. See, FIG. 67.

Response (≥50% improvement from Baseline (IND) in the MADRS total score)and Remission (MADRS total score is ≤12) rates are presented for the INDand OP/MA phases in Tables 149 and 150, respectively.

At End Point in the IND phase, the response rate was 78.4% and remissionrate was 47.2%; of the responders proceeding to the OP/MA phase, 76.5%were responders and 58.2% were remitters at endpoint. Functionalrecovery measured by SDS followed with some lag time after moodimprovement. At endpoint of the IND, remission rate measured by SDS atendpoint of the IND phase (21.1%, observed case). The remission ratedoubled throughout the OP/MA phase (25.2% at week 4 to 51.1% at week 48,observed case). See, FIG. 68.

TABLE 149 Response and Remission Rates Based on Montgomery-AsbergDepression Rating Scale (MADRS); Induction Phase (Study ESKETINTRD3004:Full (IND) Analysis Set) Response Remission Intranasal Esk + Oral ADIntranasal Esk + Oral AD Day 8  86/739 (11.6%) 54/739 (7.3%) Day 15185/702 (26.4%) 115/702 (16.4%) Day 22 312/683 (45.7%) 199/683 (29.1%)Day 28 581/688 (84.4%) 349/688 (50.7%) End Point (IND) 593/756 (78.4%)357/756 (47.2%) A subject is defined as a responder at a given timepoint if the percent improvement from baseline (IND) in MADRS totalscore is at least 50%. A subject is in remission at a given time pointif the MADRS total score is ≤12.

TABLE 150 Response and Remission Rates Based on Montgomery-AsbergDepression Rating Scale (MADRS); Optimization/Maintenance Phase (StudyESKETINTRD3004: Full (OP/MA) Analysis Set) Response Remission IntranasalEsk + Oral AD Intranasal Esk + Oral AD Week 1 513/583 (88.0%) 325/583(55.7%) Week 8 408/530 (77.0%) 277/530 (52.3%) Week 16 355/446 (79.6%)273/446 (61.2%) Week 24 278/346 (80.3%) 203/346 (58.7%) Week 32 226/284(79.6%) 178/284 (62.7%) Week 40 171/210 (81.4%) 127/210 (60.5%) Week 48124/139 (89.2%)  95/139 (68.3%) End Point (OP/MA) 461/603 (76.5%)351/603 (58.2%) A subject is defined as a responder at a given timepoint if the percent improvement from baseline (IND) in MADRS totalscore is at least 50%. A subject is in remission at a given time pointif the MADRS total score is ≤12.

Patient Health Questionnaire (PHQ-9) Total Score

The PHQ-9 is a 9-item, self-report scale assessing depressive symptoms.Each item is rated on a 4-point scale (0=Not at all, 1=Several Days,2=More than half the days, and 3=Nearly every day), with a total scorerange of 0-27. A higher score indicates greater severity of depression.

The mean change (SD) from Baseline (IND) in PHQ-9 total score to EndPoint (IND) was −8.9 (6.67) for esketamine+oral AD. The mean change (SD)from Baseline (OP/MA) in PHQ-9 total score to End Point (OP/MA) was −0.2(5.65) for esketamine+oral AD. See, FIG. 69.

Example 6

While ketamine is well known for its neurotoxic potential in rats,esketamine has not been investigated in this respect. A single andrepeated dose neurotoxicity study were conducted in 12 to 14 weeks oldfemale Sprague-Dawley rats in order to investigate whether intranasalinstillation of esketamine HCl at a single dose up to 72 mg or during 14consecutive days at doses up to 54 mg/day results in histopathologicalevidence of neurodegeneration (necrosis) in the brain. Prominent centralnervous system-related clinical signs were noted in the esketamineHCl-treated rats including dose-related salivation, ataxia, decreasedmotor activity accompanied by decubitus and catalepsy, increased motoractivity, bradypnea and audible respiration. Extensive brainhistopathology examinations showed no morphological evidence of neuronaldegeneration. In rats that received a single subcutaneous injection ofthe positive control (+)MK-801 maleate, neuronal necrosis was observedas expected in the posterior cingulate gyrus and the retrosplenialcortex. The esketamine C_(max)- and AUC-based safety margins comparedwith the maximum 84 mg dose in humans were approximately 60- and 86-foldin the single dose neurotoxicity study, and approximately 17- and11-fold in the 14-day neurotoxicity study, respectively.

1. Introduction

This study includes a single dose and 14-day repeated dose neurotoxicitystudies with intranasally administered esketamine in female rats 12 to14 weeks of age. These studies were conducted to investigate whethersingle or repeated intranasal administrations of esketamine inducedneurodegenerative changes in the rat brain. The study results were usedto estimate an esketamine exposure-based safety margin compared with themaximum dose of esketamine administered intranasally to depressed adultpatients in clinical trials.

2. Material and Methods

2.1. Test Facility

The single dose and 14-day repeated dose neurotoxicity studies wereperformed at Janssen Research & Development (JRD), a division of JanssenPharmaceutica NV, in Beerse, Belgium. Janssen Pharmaceutica NV is apharmaceutical company of Johnson & Johnson. The test facility wasapproved by the Association for Assessment and Accreditation ofLaboratory Animal Care International (AAALAC). All animals were treatedhumanely and cared for in accordance with the European (EuropeanConvention (ETS No. 123) for the protection of Vertebrate Animals Usedfor Experimental and Other Scientific Purposes. Council Directive ofNov. 24, 1986 (86/609/EEG) on the approximation of laws, regulations andadministrative provisions of the Member States regarding the protectionof animals used for experimental and other scientific purposes,complemented with the COMMISSION RECOMMENDATION of 18 Jun. 2007(2007/526/EC) on guidelines for the accommodation and care of animalsused for experimental and other scientific purposes) and Belgian(Belgian Law (Oct. 18, 1991): Protection of Vertebrate Animals used forExperimental and other Scientific Purposes. Royal Decree of Nov. 14,1993 for the protection of laboratory animals) guidelines, and with theprinciples of euthanasia as stated in the Report of the AmericanVeterinary Medical Association Panel (American Veterinary MedicalAssociation (AVMA), 2013. AVMA Guidelines for the Euthanasia of Animals,2013 Edition. American Veterinary Medical Association (AVMA),Schaumburg). The studies were performed in accordance with JRD ethicalprotocols, which were approved by the local ethical committee.

2.2. Regulations

All activities were carried out in compliance with the current GoodLaboratory Practice (GLP) principles of the OECD (Organization ofEconomic Co-operation and Development; OECD, 1998. OECD Series onprinciples of good laboratory practice and compliance monitoring. No. 1,Principles on Good Laboratory Practice. Accessed from:http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=env/mc/chem(98)17&doclanguage=en).OECD Principles of GLP are accepted by Regulatory Authorities throughoutthe Member Countries of the OECD organization as described in the MutualAcceptance of Data document (12 May 1981—C(81)30/Final, Amended on 26Nov. 1997-C(97) 186/Final). Outsourcing and monitoring of thebioanalysis of esketamine was done according to the OECD principles ofGLP to the organization and management of multi-site studies (OECD,2002. OECD Series on principles of good laboratory practice andcompliance monitoring. No. 13, The application of the OECD principles ofGLP to the organisation and management of multi-site studies. Accessedfrom:http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?docianguage=en&cote=env/jm/mono(2002)9).The bioanalysis part of the study was conducted in compliance with theUS FDA's GLP Regulations for Nonclinical Laboratory Studies, 21 CFR Part58 (FDA, 2014. FDA 21 CFR Part 58 Good Laboratory Practice forNonclinical Laboratory Studies. United States Food and DrugAdministration (FDA)), and in accordance with the appropriate JRDstandard operating procedures. The design of this study was based oninternational guidelines (European Union (2001). Directive 2001/83/EC ofthe European Parliament and of the Council of 6 Nov. 2001 on theCommunity code relating to medicinal products for human use; FDA, 2007.Toxicological principles for the safety assessment of direct foodadditives and color additives in food. Redbook 2000. FDA (United StatesFood and Drug Administration); ICH Guideline S3A, 1994. Note forguidance of toxicokinetics: the assessment of systemic exposure intoxicity studies; ICH Guideline M3 (Rs), 2009. Guidance on Non-clinicalsafety studies for the conduct of human clinical trials and marketingauthorization for pharmaceuticals; JMHW, 1995. Japanese Guidelines forNon-clinical Studies of Drugs Manual 1995. Yakuji Nippo, Tokyo. JMHW(Japanese Ministry of Health and Welfare); OECD, 2008. Test No. 407:Repeated Dose 28-day Oral Toxicity Study in Rodents, OECD Guidelines forthe Testing of Chemicals, Section 4, OECD Publishing, Paris. DOI:http://dx.doi.org/10.1787/9789264070684-en).

2.3. Animals and Housing

For these studies, female specific pathogen free (SPF) Sprague-Dawleyrats were used, which were approximately 12 to 14 weeks at start ofdosing and weighed between 227 to 293 grams in the single dose study andbetween 235 to 296 grams in the 14-day repeated dose study. The ratswere supplied by Charles River (Sulzfeld, Germany). They were grouphoused in polysulphone cages with floor area of 3000 cm² and Corn Cob(size 12, Eurocob, France) was provided as bedding material.Environmental enrichment existed of a rodent retreat (Bio-Serv, US) andaspen wood blocks (Datesand, UK). The animal room was air-conditioned(own supply of filtered fresh air) and had a 12 hour light cycle (300Lux at 1 m height). The animals were fed ad libitum with irradiatedR/M-H pelleted maintenance diet from Ssniff (Germany). Hydrogelt™(supplied by Bio-services, Uden, the Netherlands) was provided to theMK-801 dosed rats in the single dose study.

2.4. Formulations

2.4.1. Esketamine HCl

The clinical investigational product is an aqueous solution of the drugsubstance, esketamine hydrochloride (HCl). This formulation isadministered intranasally to patients using a dual nasal spray device,which delivers one spray into each nostril. At room temperature themaximum solubility of esketamine HCl at pH 4.5 is 207 mg/mL (i.e., 180mg esketamine base/mL when applying a factor 1.15 to convert theesketamine HCl salt to esketamine base concentration). The formulationwas stored at 37° C. for stability reasons until dosing.

2.4.2. (+)MK-801 maleate

An aqueous solution of (+)MK-801 maleate with pyrogenic-free watercontaining NaOH/HCl to pH 4.5 and mannitol till isotonic was used as thepositive control. A factor of 1.52 was used to convert the maleate saltinto base dose levels.

2.4.3. Vehicle

The clinical investigational formulation without esketamine HCl was usedas the vehicle.

2.5. Experimental Design of the Single Dose Neurotoxicity Study

Esketamine HCl was instilled intranasally at doses of 0 (vehicle), 36,54 or 72 mg (expressed as esketamine base) to female rats on a singleday. The dose levels were obtained by 2, 3 or 4 subsequent intranasalinstillations, respectively, into both nostrils at a volume of 50 μL pernostril. At each instillation, the second nostril was dosed immediatelyafter the first nostril. The interval between subsequent instillationsinto both nostrils was 5 minutes.

The vehicle control group received 4 subsequent intranasal instillationsof the vehicle into both nostrils (50 μL per nostril) with 5-minuteintervals.

The positive control (+)MK-801 maleate was injected once subcutaneouslyat 1 mg/kg body weight (expressed as base). The injection volume was 5mL/kg.

The vehicle- and the 36 and 54 mg-dosed groups consisted of 24 animalsper group, while the 72 mg-dosed and positive control groups involved 30animals per group. Four satellite animals were added to the esketamineHCl-dosed groups of main study animals for toxicokinetic (TK) purposes.In these animals the plasma exposure to esketamine was measured on theday of dosing at various time points up to and including 24 hours afterthe first instillation.

In order to prepare for brain histopathology examination, all main studyanimals were perfused at necropsy. Prior to the perfusion, rats wereanesthetized with isoflurane. After injection of 0.1 ml heparin, theblood of the rat was flushed out with a physiological saline solution byintraarterial insertion of a needle in the abdominal aorta. Thereafterthe rat was perfused with glutaraldehyde 3% in potassium phosphate 0.09Mand 1.4% sucrose. Due to logistic constraints at maximum 30 animalscould undergo the whole-body perfusion procedure on a given day.Therefore, a staggered start of treatment was applied to all 5 groups ofmain study animals. Consequently, subgroups of 4 main study animals ofthe vehicle- and 36 and 54 mg-dosed groups, and 5 main study animals ofthe 72 mg-dosed and positive control groups, were dosed on 6 consecutivedays, respectively. Table 151 summarizes the study design of the singledose neurotoxicity study.

TABLE 151 Design of the single dose neurotoxicity study Vehicle- andesketamine HCl-dosed groups of main study animals¹ Volume instilledintranasally into Dose Dose Group Dose each nostril per rat per ratConcentration number groups (μl) (μl) (mg) (mg/ml) 1 Vehicle 4*50 4*1000 0 2 Low 2*50 2*100 36 180 3 Medium 3*50 3*100 54 180 4 High 4*50 4*10072 180 Positive control group treated with (+)MK-801 maleate² Group DoseConcentration number (mg/kg body weight) (mg/ml) 5 1 0.2 ¹Singletreatment session consisting of multiple intranasal instillations on agiven day; ²Single subcutaneous injection

The vehicle control, positive control, and esketamine HCl-dosed animalswere sacrificed at either 48 hours (i.e., the first 12 or 15 rats pergroup) or 96 hours after the dose administration time (i.e., the last 12or 15 rats per group). The brain tissue of the vehicle control-,positive control- and esketamine HCl-treated rats were processed at thesame time and handled in the same way in batches of 4 or 5 animals pergroup.

2.6. Experimental Design of the 14-Day Repeated Dose Neurotoxicity Study

Esketamine HCl was administered into each nostril of female rats at avolume of 50 μl per nostril either once, twice or thrice daily byintranasal instillation for 14 consecutive days at doses of 0 (vehicle),18, 36 or 54 mg/day. At each instillation, the second nostril was dosedimmediately after the first nostril. The interval between subsequentinstillations into both nostrils was 5 minutes when dosed 2 or 3 timesper day.

The vehicle control group received 3 subsequent intranasal instillationsof the vehicle into both nostrils (50 μL per nostril) with 5-minuteintervals for 14 consecutive days.

The positive control group received a single subcutaneous injection of(+)MK-801 at 48 hours prior to the necropsy of the vehicle control andesketamine HCl-treated animals. The dose level of (+)MK-801 maleate was1 mg/kg body weight.

Each group of main study animals consisted of 12 female rats. Foursatellite animals were added to the esketamine HCl-dosed groups of mainstudy animals for TK purposes. The plasma exposure to esketamine wasmeasured in these animals on the first and the last day of dosing atvarious time points up to and including 24 hours after the firstinstillation.

Due to logistic constraints associated with the whole body perfusionprocedure of the animals at necropsy, a staggered start was applied tothe study. Consequently, all 5 groups of main study animals were dividedinto three subgroups of 4 animals each. For each of these subgroupstreatment started on a different day. The perfusion procedure is the isthe same as described for the single dose study. Table 152 summarizesthe study design of the 14-day repeated dose neurotoxicity study.

TABLE 152 Design of the 14-day repeated dose neurotoxicity studyVehicle- and esketamine HCl-dosed groups of main study animals¹ Volumeinstilled intranasally into Dose Dose Group Dose each nostril per ratper rat Concentration number groups (μl/day) (μl/day) (mg/day (mg/ml) 1Vehicle 3*50 3*100 0 180 2 Low 1*50 1*100 18 180 3 Medium 2*50 2*100 36180 4 High 3*50 3*100 54 180 Positive control group treated with(+)MK-801 maleate² Group Dose Concentration number (mg/kg body weight)(mg/ml) 5 1 0.2 ¹Daily treatment sessions each consisting of a single(group 2) or multiple intranasal instillations (groups 1, 3 and 4).²Single subcutaneous injection

All vehicle- and esketamine HCl-treated animals were sacrificed at 48hours after the last instillation. All (+)MK-801 maleate-treated animalswere sacrificed at 48 hours post-dose. The brain tissue of the vehiclecontrol-, positive control- and esketamine HCl-treated rats wereprocessed at the same time and handled in the same way in batches of 4animals per group.

2.7. Examined Parameters in the Single Dose and Repeated DoseNeurotoxicity Studies

All animals were checked at least once daily for ill health, abnormalbehavior or unusual appearance, clinical signs, toxic or pharmacologicalresponse, moribund state or mortality. Furthermore, clinicalobservations were recorded for the esketamine HCl-dosed rats on the dayof dosing at 0 till 5 minutes, 15 and 30 minutes, and at 1, 2, 4, 6hours post-dose, at the end of the working day and at 24 hours after thelast instillation in the single dose study and on the first day ofdosing, after one week and towards the end of the dosing period in therepeated dose study. Body weight and body weight gain were measureddaily. Food consumption was measured weekly in the repeated dose study.

On the day of terminal kill, a complete physical examination wasperformed on the rats in fasted condition and body weight was recorded.The surviving animals were anaesthetized by inhalation of an isoflurane(IsoFlo Zoetis, Belgium)/oxygen mixture and killed by exsanguination viathe carotid artery. A full necropsy was performed on all animals and allmacroscopic changes were recorded. All terminally killed rats or thosekilled pre-terminally were perfused with 4% paraformaldehyde in thesingle dose study and with glutaraldehyde 3% in potassium phosphatebuffer 0.09 M with 1.4% sucrose in the repeated dose study.

Brain tissue was sampled and processed routinely. The trimmed andembedded tissue was sectioned and stained with hematoxylin-eosin (HE).Histoprocessing and staining were carried out in three batches of 4animals per group (each batch thus containing 4 animals from vehiclecontrol-, positive control- and the three esketamine HCl-treatedgroups). In the single dose study duplicate brain sections were stainedwith Fluoro-Jade (FJ).

All tissues showing gross abnormalities were examined macroscopically.Histopathological examination was performed on 7 levels of brain tissueaccording to Bolon (2013. Toxicol. Pathol. 41(7), 1028-1048) from thevehicle control-, positive control-, and high dose esketamineHCl-treated groups in the single dose study, and in all groups in therepeated dose study.

The microscopic finding of neuronal necrosis in the PCG/RSC of the brainwas graded unilaterally according to the number of necrotic neuronsobserved over the total length of the PCG/RSC structure visible in thetissue section (usually around 3-5 mm) utilizing the following criteria:

Grade 1: minimal histological change (<10 necrotic neurons),

Grade 2: slight histological change (10-20 necrotic neurons),

Grade 3: moderate histological change (20-30 necrotic neurons) or

Grade 4: marked histological change (>30 necrotic neurons)

2.8. Statistical Analyses

The significance of differences between each dose group and the vehiclegroup was assessed by a one-sided Fisher Exact Probability test formortality and histopathology, a two-sided Fisher Exact Probability testfor clinical observations and a two-sided Mann-Whitney U test for bodyweight and weight gain. No statistical analysis was conducted for foodconsumption and gross pathology. All tests were performed at asignificance level of five percent (α=0.05).

3. Results 3.1 Single Dose Study 3.1.1. Esketamine HCl

No test article related mortality or gross pathology changes were notedwhen female rats were dosed once with esketamine HCl up to 54 mg. Norelevant effects were noted on body weight up to 72 mg.

At 72 mg two main study animals and two satellite TK animals died within30 minutes after having received 4 instillations of esketamine HCl intoboth nostrils. Clinical signs noted just before death were ataxia,bradypnea, severely decreased general activity, decubitus, catalepsy(rigid posture), and salivation. One of these rats also showed narrowedpalpebral fissures. The two main study animals were necropsied and grosschanges were observed in the lungs (discoloration [in one rat], andswollen aspect) and the pleural cavity (hemorrhagic aspect). A cause ofdeath could not be determined. However, the mortalities were consideredrelated to the combination of the large dose volume and the high dose ofesketamine HCl.

Prominent clinical observations were noted in all dose groups ofesketamine HCl. Salivation, audible respiration, ataxia and in general aslight increase in general activity were noted directly after dosing.Subsequently, severely decreased activity accompanied by decubitus,bradypnea, ptosis and catalepsy were observed from <15 minutes post-doseonwards. The duration of these findings was dependent on the dose ofesketamine HCl. At 36 mg, these findings were noted mainly up to 15-30minutes, at 54 mg up to 30 minutes to one hour, and at 72 mg up to 1-2hours after the last instillation. During this time period narrowedpalpebral fissure occurred in a dose-dependent manner affectingapproximately one third of the animals at 36 mg up to approximately twothirds of the animals at 72 mg. After the decrease in activity hadgradually subsided, ataxia was again observed in most animals and lastedapproximately 1.5 hours at 36 mg, 1.5 to 3 hours at 54 mg, and up to 3hours or longer at 72 mg. The ataxia was accompanied by slightly (orincidentally moderately) increased general activity in approximatelyhalf of the rats. Audible respiration was noted after dosing inapproximately half of the animals dosed at 36 mg, and in 2 or 3 rats at54 and 72 mg, respectively. All findings except for audible respirationfully subsided within 24 hours. In one high dose rat audible respirationwas still present on Day 2. More details can be found in Table 153. Thetime course of decreased and increased general activity is illustratedin FIG. 70.

TABLE 153 Main clinical observations: incidences per group VehicleEsketamine HCl Positive control 36 mg 54 mg control Observation X/N X/NX/N 72 mg X/N Ataxia 0/24 24/24 *** 24/24 *** *** 27/30 *** Catalepsy0/24 20/24 *** 23/24 *** 30/30 *** 15/30 *** Chromodacryorrhea 0/240/24   0/24   0/30   24/30 *** Decubitus 0/24 23/24 *** 23/24 *** 30/30*** 30/30 *** Decreased general activity 0/24 23/24 *** 23/24 *** 30/30*** 30/30 *** Increased general activity 0/24 24/24 *** 24/24 *** 29/30*** 4/30   Piloerection 0/24 0/24   0/24   0/30   8/30**  Narrowedpalpebral fissure 0/24 7/24**  10/24 *** 22/30 *** 4/30   Abnormalrespiration 0/24 22/24 *** 22/24 *** 30/30 *** 12/30 *** audiblerespiration 0/24 10/24 *** 3/24   2/30   0/30   bradypnoea 0/24 22/24*** 21/24 *** 30/30 *** 12/30 *** Salivation (out of normal) 0/24 23/24*** 24/24 *** 29/30 *** 17/30 *** Significance for 36, 54 and 72 mgesketamine HCl-treated and positive control group(s) computed versusvehicle by Fisher Exact probability test (one-tailed right probability):*p < 0.05; **p < 0.01; *** p < 0.001; X = number of affected animals; N= total number of animals.

Although mortality and prominent CNS-findings (e.g. catalepsy) werenoted, histopathological lesions were absent in the brain of esketamineHCl-treated rats sacrificed at either 48 or 96 hours after a single doseof 72 mg. In particular no Olney lesions were found in the PCG/RSC ofany esketamine HCl-treated animal. More details can be found in Table155 (see Section 3.3).

The C_(max)- and AUC-based safety margins for esketamine compared withthe maximum 84 mg clinical dose were approximately 60- and 86-fold,respectively.

3.2. Repeated Dose Study

3.2.1. Esketamine HCl

No test article related mortality occurred. Body weight, weight gain,and food consumption were unaffected when female rats were dosed withesketamine HCl up to 54 mg/day for 14 days.

At all dose levels of esketamine HCl, a dose-dependent increase induration of ataxia and salivation was recorded. Slightly increasedgeneral activity was noted in all esketamine HCl-dosed animals startingat 5 minutes after dosing and lasting up to 1 or 2 hour after the lastdaily dose administration. This increased motor activity was seen dailyat 18 mg/day, from Day 3 to 5 until the end of the study at 36 mg/day,and mainly during the last week of the study at 54 mg/day. Also a slightto severe decrease in general activity was seen in all animals with adose-related increase in severity and duration (from 15 or 30 minutes upto 1 or 2 hours after dosing). Decubitus was occasionally noticed duringthe first days of the study at 36 and 54 mg/day. After the decrease inactivity had gradually subsided, increased general activity accompaniedby ataxia was again observed (FIG. 71A to FIG. 71C). At 36 or 54 mg/day,periods of respiratory abnormalities (bradypnoea, audible respiration)were noted in almost all animals and were observed on several daysthroughout the study, from 5 to 30 minutes or 1 to 4 hours after dosing.More details can be found in Table 154.

TABLE 154 Main clinical observations in the repeated dose neurotoxicitystudy (incidences per group) Vehicle Esketamine HCl Positive control 18mg/day 36 mg/day 54 mg/day control Observation X/N X/N X/N X/N X/NAtaxia 0/12  12/12*** 12/12*** 12/12*** 12/12*** Chromodacryorrhea 0/120/12 0/12  0/12  12/12*** Decubitus 0/12 0/12 2/12   8/12*** 0/12 Decreased general activity 1/12 5/12 12/12*** 12/12*** 12/12***Increased general activity 0/12  12/12*** 12/12*** 12/12*** 12/12***Abnormal respiration 0/12/12 2/12 11/12*** 12/12*** 12/12*** audiblerespiration 0/12 2/12 6/12** 6/12** 0/12  bradypnoea 0/12 0/12 11/12***12/12*** 12/12*** Salivation (out of normal) 0/12  12/12*** 12/12***12/12*** 2/12  Significance for 18, 36 and 54 mg/day esketamineHCl-treated and positive control group(s) computed versus vehicle byFisher Exact probability test (one-tailed right probability): *p < 0.05;**p < 0.01 ***p < 0.001; X = number of affected animals; N = totalnumber of animals; Gross pathology did not reveal any tissue changes.

At 48 hours after the last intranasal Instillation no histopathologicallesions were noted in the brain of esketamine HCl-dosed animals up to 54mg/day. Notably no Olney lesions were found in the PCG/RSC of anyesketamine HCl-treated animal. More details can be found in Table 6 andFIGS. 72A, 72B, and 73 (see Section 3.3).

In the 14-day study the C_(max)- and AUC-based safety margins foresketamine were approximately 17- and 11-fold, respectively.

3.3. Results for (+)MK-801 Maleate in the Single Dose and Repeated DoseNeurotoxicity Studies with Esketamine HCl

No mortality was noted in either the single dose or repeated dose studywhen female rats received a single subcutaneous dose of (+)MK-801maleate at 1 mg/kg body weight.

Ataxia, moderately to severely decreased general activity and decubituswere noted in most animals. Additionally, catalepsy, bradypnea, tremorsand salivation were noted. A single animal showed clonic convulsions.

During the follow-up period prior to necropsy, decreased activity andataxia remained present, but became gradually less severe, and catalepsyand bradypnea were only noted occasionally. Additionally almost allanimals showed chromodacryorrhea. Other signs of general discomfort wereoccasionally noted in some animals such as piloerection, hunched back,ocular discharge and narrowed palpebral fissures. Occasionally slightincreases in general activity were noted. The time course of decreasedand increased activity is illustrated in FIG. 70.

(+)MK-801 maleate-dosed rats showed approximately 13-14% body weightloss within the first 48 hours after treatment. In the single dosestudy, where half of the animals was maintained until 96 hourspost-dose, the animals regained weight between 48 and 96 hourspost-dose.

At 48 and 96 hours post-dose in the single dose study, and at 48 hoursafter the last dose administration in the repeated dose study, (+)MK-801maleate induced Olney lesions as evidenced by the occurrence of neuronalnecrosis in the PCG/RSC of all animals treated with this positivecontrol test article. In both studies, most lesions were graded asmoderate or marked (grade 3 or 4). There was no remarkable difference inthe severity of the neuronal necrosis between the animals necropsied ateither 48 or 96 hours post-dose in the single dose study. In that study,necrotic neurons tended to be slightly more numerous upon FJ stainingcompared with the HE staining. In both studies the lesions wereconsistently more severe in the RSC compared with the PCG.

Tables 155 and 156 below provide an overview of the incidences andseverity.

TABLE 155 Single dose neurotoxicity study. Incidence and severity ofneuronal necrosis in the posterior cingulate gyrus (PCG) and theretrosplenial cortex (RSC) of esketamine HCl- and (+)MK-801maleate-treated rats Dose of esketamine HCl (mg) Vehicle Esketamine HClPositive control 36 54 72 control BRAIN, POSTERIOR CINGULATE GYRUS (HE)No. Examined 24 — — 30 30 Neuronal Necrosis — — — —  30** Grade 1 — — ——  1 Grade 2 — — — —  5 Grade 3 — — — — 19 Grade 4 — — — —  5 BRAIN,POSTERIOR CINGULATE GYRUS (Fluoro-Jade) No. Examined 24 — — 30 30Neuronal Necrosis  30** Grade 2 — — — —  2 Grade 3 — — — —  9 Grade 4 —— — — 19 BRAIN, RETROSPLENIAL CORTEX (HE) No. Examined 24 — — 30 30Neuronal Necrosis  30** Grade 1 — — — —  1 Grade 2 — — — —  6 Grade 3 —— — — 10 Grade 4 — — — — 13 BRAIN, RETROSPLENIAL CORTEX (Fluoro-Jade)No. Examined 24 — — 30 30 Neuronal Necrosis  30** Grade 3 — — — —  5Grade 4 — — — — 25 Significance for 36, 54 and 72 mg esketamineHCl-treated and positive control group(s) computed versus vehicle byone-sided Exact Fisher test: *p ≤ 0.05; **p ≤ 0.01.

TABLE 156 Repeated dose neurotoxicity study. Incidence and severity ofneuronal necrosis in the posterior cingulate gyrus (PCG) and theretrosplenial cortex (RSC) of esketamine and (+)MK-801 maleate-treatedrats Dose of esketamine HCl (mg/day) Vehicle Esketamine HCl Positivecontrol 18 36 54 control BRAIN, POSTERIOR CINGULATE GYRUS (HE) No.Examined 12 12 12 12 12  Necrosis  12** Grade 1 — — — — 1 Grade 2 — — —— 4 Grade 3 — — — — 4 Grade 4 — — — — 3 BRAIN, RETROSPLENIAL CORTEX (HE)No. Examined 12 12 12 12 12  Necrosis  12** Grade 1 — — — — 1 Grade 2 —— — — 1 Grade 3 — — — — 3 Grade 4 — — — — 7 Significance for 18, 36 and54 mg/day esketamine HCl and positive control group(s) computed versusvehicle by one-sided Exact Fisher Test: *p ≤ 0.05; **p ≤ 0.01

4. Discussion

Ketamine is a drug with contradictory properties ascribed to it. On onehand, it can be neuroprotective (Hudetz, 2010. J. Cardiothor. Vasc.Anesth. 24, 131-142), as for example was shown by the decreases inplasma catecholamines and the improved outcome from incomplete cerebralischemia in rats (Hoffman, 1992. J. Anesthesiology 76(5), 755-762). Areduction in neuronal degeneration and anxiety levels was observed whenketamine was administered during early life-induced status epilepticusin rats (Loss, 2012. Brain Research 1474, 110-117). In a rat model ofglobal forebrain ischemia induced by hypobaric hypotension, a single IPadministration of esketamine at 60 or 90 mg/kg body weight 15 minutesafter cerebral ischemia significantly reduced neuronal cell loss in thecerebral cortex, whereas other brain structures such as hippocampus wereless protected (Proescholdt, 2001. Brain Res. 904, 245-251). On theother hand, ketamine has been reported to provoke Olney lesions in therat brain after a single (Olney 1989; Jevtovic-Todorovic 2000;Jevtovic-Todorovic 2005) or repeated dose administration (Horváth, 1997.Brain Res. 753(2), 181-195). The precise thresholds for dose andduration of exposure causing neurotoxicity in animals remain to beestablished. The relevance to humans of ketamine's neurotoxic action inanimals is unknown.

The potential induction of neuronal lesions after an acute intranasaladministration of esketamine HCl was studied in the single doseneurotoxicity study in which adult female Sprague-Dawley rats (12 to 14weeks of age) received doses of 36, 54 or 72 mg. These doses wereachieved by a single treatment session consisting of 2, 3 or 4subsequent intranasal instillations, respectively, into each nostril of50 μL of an aqueous solution containing 180 mg/mL of esketamine HCl. Theinterval between the subsequent instillations of both nostrils was 5minutes. The highest dose of 72 mg represented the maximum feasible dosefor an acute study based on the maximum dose volume that could beadministered multiple times at 5-minute intervals (50 μL per nostril)and the maximum solubility of esketamine HCl in water being 180 mg/mL.Consequently, the highest dose of 72 mg each nostril was instilled within total 200 μL of esketamine HCl spread over 15 minutes. A higher dosevolume was not feasible considering that the rat is an obligate nasalbreather with a nasal cavity which has a volume of approximately 200 μLper nostril (Gizurarson, 1990. Acta Pharm. Nord. 2(2), 105-122). Brainhistopathology was examined at 48 hours and 96 hours post-dose. Theselection of these time points was guided by published experimentsreporting that acute exposure to MK-801 or (+)MK-801 depending on thedose, induces neuronal necrosis in the PCG/RSC of rats at 1 to 14 daysafter single dose administration (Auer 1996; Bender, 2010a. Neuroscience169, 720-732; Colboume 1999; De Olmos, 2009. Neuroscience 164(3),1347-1359; Fix 1993; Fix 1994; Fix 1995; Fix 1996; Fix 2000;Jevtovic-Todorovic 2001; Willis, 2007. NeuroToxicology 28, 161-167). Nosigns of neuronal necrosis were found at these two time points in any ofthe esketamine HCl-treated animals tested in the single dose study. TheC_(max)- and AUC-based safety margins for esketamine compared with themaximum 84 mg clinical dose were approximately 60- and 86-fold,respectively.

To date, no previous literature data exist on the potential induction ofneuronal necrosis in the PCG/RSC of adult female Sprague Dawley ratsacutely treated with either esketamine or ketamine. There is howeverample evidence that ketamine induces neuronal vacuolation in these brainareas of female rats shortly after single dose treatment. In thisrespect ketamine resembles MK-801 or (+)MK-801 (Auer and Coulter 1994;Farber 1995; Fix 1993; Fix 1994; Fix 1996; Fix 2000; Jevtovic-Todorovic,1997. Journal of Cerebral Blood Flow and Metabolism 17, 168-174;Jevtovic-Todorovic 2001). Neuronal vacuolization was observed in thePCG/RSC of adult Sprague Dawley rats at 4 hours after a singlesubcutaneous injection with ketamine at 40 mg/kg body weight, but not at10 or 20 mg/kg (Olney 1989). The RSC of female Sprague Dawley rats 2months of age, which received a single dose of ketamine at 60 mg/kg bodyweight, showed neuronal vacuolation at 3 hours post-dose. The reactionwas more prominent at 3 months of age (Jevtovic-Todorovic 2001). TheED₅₀-value for the induction of neuronal vacuolation in the PCG/RSC ofadult female Sprague Dawley rats at 3 hours after a singleintraperitoneal injection of ketamine has been reported to be 47.5 mg/kgbody weight (Jevtovic-Todorovic 2000). Such early time points after doseadministration were not examined in the single dose neurotoxicity study,because neuronal vacuolation is considered to be reversible. The latterneurodegenerative lesion is thought to be more severe than neuronalvacuolation and irreversible (Bender 2010a; Zhang 1996).

In the current single dose study with intranasally administeredesketamine HCl in Sprague Dawley rats, the mean body weight was 255 g.Therefore, the highest dose of 72 mg corresponds with approximately 282mg/kg body weight. This dose is considerably larger than the dose levelsof ketamine previously described to provoke vacuolated neurons in thePCG/RSC (Olney 1989; Jevtovic-Todorovic 2000; Jevtovic-Todorovic 2005).It is not clear why no histopathological neuronal lesions were presentafter a single intranasal dose of 282 mg/kg body weight esketamine,while neuronal vacuolation was observed from a single intraperitonealinjection of 47.5 mg/kg body weight ketamine onwards. A possible reasoncould be that in the current study, neuronal necrosis was studied 48 and96 hours after an acute dose of esketamine, while the literature withketamine only describes neuronal vacuolation some hours after acuteadministration. Perhaps the neuronal vacuolation was not observedbecause it recovered by the 48 hour time point (as shown by Auer andCoulter 1994 for MK-801). Another reason could be that intranasallyadministered esketamine and parenterally administered ketamine differ inbioavailability and hence result in different plasma exposures and/ordifferent brain kinetics.

Olney lesions or other neuropathological changes of the rat brain afterrepeated dosing of esketamine or ketamine have not been reported.Additionally, neuropathological examinations of the rat brain afterrepeated dosing of MK-801 are scarce in the open literature. The brainsof rats SC treated with 0.3 mg/kg body weight/day of MK-801 on 4consecutive days did not show neuronal vacuolation at 4 hours after thelast dose administration (Olney 1989). When rats were treated daily withMK-801 for 4 days at higher or more steeply increasing dose schedules,and the brains were examined 4 hours after the last dose, neuronalvacuolation was observed. There was no evidence of a cumulative effector of the reaction progressing to an irreversible state (Olney 1989). Inrats treated 3 times/day with (+)MK-801 for two days, neurodegenerationwas reported not only in the RSC, but in other brain areas as wellalthough less prominent (Horváth 1997).

To investigate the potential formation of neurodegenerative lesionsafter repeated intranasal administration of esketamine HCl, a 14-dayrepeated dose neurotoxicity study was performed in Sprague Dawley ratsof the same sex and age as used in the single dose study. The highestdose of 54 mg/day esketamine HCl was selected based on a 14-daydose-range finding study, where upon repeated intranasal administrationthis dose level was considered to be the maximum tolerated dose (MTD) onthe basis of severely decreased general activity, decubitus andrespiratory abnormalities (internal study). In the 14-day neurotoxicitystudy, the vehicle control and esketamine HCl-dosed animals weresacrificed at 48 hours after the 14^(th) dose administration ofesketamine, and the (+)MK-801-treated animals at 48 hours after an acutedose of (+)MK-801-maleate, which was administered on the last dosing dayof the study. Fix 1996 reported neuronal necrosis in the PCG/RSC of therat brain upon a single dose of MK-801 from 24 hours to 14 dayspost-dose. At 24 hours the effect was only slight and occasionallypresent, while it was prominent at 72 hours post-dose. Fix 1993 reportedneuronal necrosis in the rat RSC at 48 hours to 14 days after a singledose of (+)MK-801. The 48-hour time point of sacrifice was selectedsince the primary goal of the study was to explore the potentialoccurrence of neuronal necrosis in the brain. Fourteen days of repeatedadministration of esketamine HCl was considered a reasonable duration oftreatment to allow detection of degenerating neurons at 48 hours afterthe last dose administration. Neuronal vacuolation was not expected tobe detectable after 14 days of treatment since it has a short timecourse and has been reported to be reversible (Auer and Coulter 1994;Bender 2010a; Farber 1995; Fix 1993; Fix 1994; Fix 1996; Fix 2000;Jevtovic-Todorovic 1997; Jevtovic-Todorovic 2000; Jevtovic-Todorovic2001; Olney 1989; Zhang 1996). Consequently, neuronal vacuolation wasnot considered an endpoint of interest. Neuronal necrosis in the PCG/RSCwas observed at 48 hours after a single dose of (+)MK-801 at 1 mg/kgbody weight, it was decided to dose the positive control group only onceon the day that the esketamine HCl-treated rats received their last doseadministration and evaluate all brain tissue samples at 48 hours afterthe last dose. While as expected the (+)MK-801 treated rats showedneuronal necrosis, the esketamine HCl-treated animals did not. At thehighest dose tested of 54 mg/day esketamine HCl, the C_(max)- andAUC-based safety margins for esketamine compared with the maximum 84 mgclinical dose were approximately 17- and 11-fold.

When esketamine HCl was administered intranasally to adult female ratsonce up to 72 mg (corresponding to approximately 282 mg/kg body weight)or repeatedly up to 54 mg/day (corresponding to approximately 196 mg/kgbody weight), similar clinical observations were noted. The duration ofanesthesia was 15-30 minutes at 36 mg, 30 minutes to an hour at 54 mg,and one to 2 hours for the 72 mg-dosed rats. During the anestheticperiod, bradypnea was occasionally observed. Although ketamine is seenas an agent causing minimal respiratory depression, some respiratorydepression may occur at higher dose levels as demonstrated by the higherpCO2 values for ketamine at 80 mg/kg body weight (Hoffmann, 2003.Pharmacology, Biochemistry and Behavior 74, 933-941). Ketamine is awidely used anesthetic in rats, but is mostly used in combination withother agents (e.g. xylazine) to induce dissociative anesthesia withanalgesia and immobility. The onset of anesthesia after intramusculardosing a rat with 50 mg/kg ketamine is rapid (within 5 minutes), withloss of righting reflex after 7 minutes and a duration of fullanesthesia for 35 minutes. 45 Minutes later the righting reflex startsto be present again. Intramuscular doses up to 150 mg/kg body weightcaused a peak effect within 10 minutes, which could be sustained for30-40 minutes. A total recovery of the anesthesia was seen after 1.5hours (Green 1981. Lab. Anim. 1981, 15: 163).

The esketamine HCl-induced anesthesia was mostly preceded by ataxia andslightly increased activity of the rats during the first minutes afterdosing, before decubitus and catalepsy was noted within 15 minutes.Hyperactivity and ataxia were also noted after recovery from anesthesiaand lasted approximately up to 1.5 hours at 36 mg, up to 1-3 hours at 54mg and up to 3 hours or longer at 72 mg. Subanesthetic doses of ketamineare known to cause hyperactivity and ataxia. An intraperitoneal dose of10 mg/kg body weight ketamine results in increased open field activity,which is thought to be related to changes in dopamine activity (Wilson,2005. Pharmacology, Biochemistry and Behavior 81 (2005) 530-534).Intravenous dosing of ketamine at 5 to 80 mg/kg body weight showed anincreased duration of ataxia and hyperactivity with increasing doses.The duration of hyperactivity was slightly longer that the duration ofataxia (Wilson 2005; Cohen 1973. Anesthesiol. 39: 370-376). Similarfindings were reported by Compton (Compton, 2013. International Journalof Life Science and Medical Research Vol. 3 Iss. 5, 179-192), as ratsinjected intraperitoneally with ketamine at 5 mg/kg showed increasedgeneral activity, while rats dosed at 40 mg/kg did not.

The positive control in both studies was (+)MK-801-maleate. Thisnon-selective NMDA receptor antagonist is well known for causingneuronal vacuolation and degeneration (necrosis) in the PCG/RSG of therat brain (Auer and Coulter 1994; De Olmos 2009; Fix 1993; Fix 1994; Fix1995; Fix 1996; Fix 2000; Olney 1989; Olney 1991). The (+)-enantiomer is7 times more potent than the (−)-enantiomer. In the present studies itwas administered by a single subcutaneous injection at 1 mg/kg. In adose-range finding study, this 1 mg/kg body weight dose was consideredto be the MTD for a single subcutaneous injection of (+)MK-801-maleatein female Sprague-Dawley rats 13-14 weeks of age. A single SC orintraperitoneal (IP) administration of MK-801 at 5 mg/kg body weight hasbeen reported to cause severe incoordination, increased motor activity,ataxia, head-waving movements prior to a recumbency period of 5.5 to 6hours for male rats and 24 to 40 hours for females. This long period ofrecumbency resulted in severe body weight losses. Mortality of rats in astate of extreme immobility with shallow breathing was reported as well(Colboume 1999; De Olmos 2008; Fix 1995; Auer 1996; Hur, 1999.Environmental Toxicology and Pharmacology 7, 143-146). Female ratsinjected IP with 5 mg/kg body weight of (+)MK-801 showed recumbency,severe hypothermia and loss of body weight lasting up to 3 to 7 dayspost-dose (Zajaczkowski, 2000. Neurotox. Res. 1(4), 299-310).Behavioural disturbance and recumbency have also been reported in ratstreated once at 10 mg/kg IP (Bender, 2010b. Neurotoxicology andTeratology 32, 542-550). A single SC dose of 1 mg/kg MK-801 inducedrecumbency for at least 7 hours post-dose (Fix 1995). At lower doselevels (0.05 to 0.2 mg/kg SC or IP) MK-801 induced increased locomotionand ataxia in rats (Andine, 1999. J. Pharmacol. Exp. Ther. 290(3),1393-408; Ahlander, 1999. Neuropsychopharmacol. 21, 414-426). In femalerats, locomotion was maximal at 0.1 to 0.2 mg/kg, while stereotypicsniffing was reported at 0.1 to 0.5 mg/kg, and ataxia at 0.2 to 1 mg/kgof MK-801 (Andine 1999). The clinical findings reported in theliterature were also observed in the studies after a single dose of(+)MK-801 at 1 mg/kg body weight. As a result of the long period ofrecumbency, the animals were not eating or drinking, causing a severebody weight loss of 13-14% during the first 48 hours after dosing. Ithas been claimed that any dose of MK-801 equal to or exceeding 0.2 mg/kgshould probably be considered to be grossly intoxicating in rats(Wozniak, 1990. Psychopharmacology 101(1), 47-56). Remarkably, however,many other investigators did not mention any clinical observations atall even after a single dose as high as 10 mg/kg (Wozniak, 1998.Neurobiology of Disease. 5(5), 305-322; Farber 1995; Auer and Coulter1994; Fix 1993; Fix 1996; Willis and Ray 2007; Bueno, 2003. Experimentaland Toxicologic Pathology 54, 319-334; Horváth 1997; De Olmos 2009; Fix2000).

The presence of the neuronal necrosis in the PCG/RSC was gradedaccording to the number of necrotic neurons that were observed over thetotal length of the structure visible in the section (usually around 3-5mm). Four grades were used and covered changes that ranged from minimal(<10 necrotic neurons) to marked (>30 necrotic neurons). With thisgrading system, it was shown that (+)MK-801 maleate upon a single SCinjection at 1 mg/kg body weight caused the typical neuronal necrosisassociated with neuronal necrosis in the PCG/RSC of all treated animals.The severity of the lesions was scored marked in the majority of theanimals (i.e., 25 out of 30 females in the single dose study and 7 outof 12 animals in the repeated dose study). No relevant differences wereseen between the single dose and repeated dose studies or between the48- and 96-hour post-dose timepoints in the single dose study. Thereforeit can be concluded that rats that were dosed once with (+)MK-801maleate at 1 mg/kg served as a valid positive control group for bothneurotoxicity studies and that the response was robust and consistent.

4.1. Conclusion

Although mortality and prominent CNS-related clinical observations (e.g.catalepsy) were noted with intranasally administered esketamine HCl inthe single dose neurotoxicity study, no neuropathological lesions wereobserved in the adult female rat brain up to the highest tested dose of72 mg when evaluated at 48 and 96 hours after dosing. The C_(max)- andAUC-based safety margins for esketamine compared with the maximum 84 mgclinical dose were approximately 60- and 86-fold, respectively. Nohistopathological lesions were found in the brains of the esketamineHCl-treated animals involved in 14-day repeat dose neurotoxicity studyeither. In the latter study, the highest tested dose was 54 mg/day. Atthat dose, the C_(max)- and AUC-based safety margins for esketaminecompared with the maximum 84 mg clinical dose were approximately 17- and11-fold. As expected, the positive control (+)MK801 maleate inducedneurodegenerative lesions as evidenced by typical neuronal necrosis inthe PCG/RSC of the brain in all rats treated with this positive controlcompound.

Example 7

The studies of this example assessed the efficacy, safety, anddose-response of intranasal esketamine in patients withtreatment-resistant depression (TRD).

Materials and Methods

Ethical Practices

An Independent Review Board (United States)/Independent Ethics Committee(Belgium) approved the study protocol and amendments. The study wasconducted in accordance with ethical principles that have their originin the Declaration of Helsinki, consistent with Good Clinical Practicesand applicable regulatory requirements. All individuals provided writteninformed consent before participating in the study. The study isregistered at clinicaltrials.gov, NCT01998958.

Study Population

The study enrolled medically stable (based on physical examination,medical history, vital signs, and 12-lead ECG performed at screening)adults (20 to 64 years) with a diagnosis of MDD, according to theDiagnostic and Statistical Manual of Mental Disorders Fourthedition—Text revised (DSM-IV-TR). See, American Psychiatric Association.Diagnostic and statistical manual of mental disorders (DSM-IV-TR). 4thed, text revised. Washington, DC: American Psychiatric Association,2000.

All participants had TRD, defined as inadequate response to ≥2antidepressants (assessed by Massachusetts General HospitalAntidepressant Treatment Response Questionnaire; Rush, “The Inventory ofDepressive Symptomatology (IDS): Psychometric properties”, Psychol.Med., 1996, 26(3):477-486), with at least 1 in the current depressionepisode. Otherwise, an antidepressant failure from a prior episode wasacceptable. All participants continued the antidepressants they weretaking at study entry during the study. At screening and pre-dose on day1, eligible participants had a score of ≥34 on the 30-item,clinician-rated Inventory of Depressive Symptomatology (IDS-C₃₀) (Rush1996 and Trivedi, “The Inventory of Depressive Symptomatology, ClinicianRating (IDS-C) and Self-Report (IDS-SR), and the Quick Inventory ofDepressive Symptomatology, Clinician Rating (QIDS-C) and Self-Report(QIDS-SR) in public sector patients with mood disorders: a psychometricevaluation”, Psychol. Med., 2004, 34(1):73-82), corresponding tomoderate-to-severe depression. Key exclusion criteria included recent orcurrent suicidal ideation with intent to act, suicidal behavior, orhomicidal ideation/intent, diagnosis of bipolar or related disorders,intellectual disability, psychotic disorder, MDD with psychosis,post-traumatic stress disorder, obsessive-compulsive disorder,substance/alcohol use disorders in the last year, and recent use ofcannabis.

The study enrolled medically stable (based on physical examination,medical history, vital signs, and 12-lead ECG performed at screening)adults (20 to 64 years) with a diagnosis of MDD, according to theDiagnostic and Statistical Manual of Mental Disorders Fourthedition—Text revised (DSM-IV-TR). Participant's major depressive episodeand treatment response were evaluated to confirm participant metcriteria using the “State vs. Trait, Assessibility, Face Validity,Ecological Validity, Rule of Three P's” (SAFER) criteria interview[Targum, “Redefining affective disorders: relevance for drugDevelopment”, CNS Neurosci. Ther., 2008, 14(1):2-9], administered byremote, independent raters.

Key exclusion criteria included recent or current suicidal ideation withintent to act, suicidal behavior, or homicidal ideation/intent,diagnosis of bipolar or related disorders, intellectual disability,psychotic disorder, major depressive disorder (MDD) with psychosis,cluster B personality disorder (based on clinical assessment by theinvestigator), post-traumatic stress disorder, obsessive-compulsivedisorder, history of non-response to electroconvulsive therapy.Individuals with substance or alcohol abuse or dependence during thepast year were excluded, as well as those testing positive for cannabisat screening.

Study Design

This phase 2, 2-panel, double-blind, doubly-randomized, delayed-start,placebo-controlled study (a variant of sequential parallel comparisondesign) was conducted from 28 Jan. 2014 to 25 Sep. 2015. See, e.g., Chi,“On clinical trials with a high placebo rate. Contemporary ClinicalTrials Communications”, 2016, 2:34-53; Fava, “The problem of the placeboresponse in clinical trials for psychiatric disorders: culprits,possible remedies, and a novel study design approach”, Psychother.Psychosom. 2003, 72(3):115-27; Chen, “Evaluation of performance of someenrichment designs dealing with high placebo response in psychiatricclinical trials”, Contemp. Clin. Trials, 2011, 32(4):592-604; Fava, “Adouble-blind, placebo-controlled study of aripiprazole adjunctive toantidepressant therapy among depressed outpatients with inadequateresponse to prior antidepressant therapy (ADAPT-A Study)”, Psychother.Psychosom., 2012, 81(2):87-97); Chen, “A sequential enriched design fortarget patient population in psychiatric clinical trials” Stat. Med.,2014, 33(17):2953-2967; Doros, “A repeated measures model for analysisof continuous outcomes in sequential parallel comparison designstudies”, Stat. Med., 2013, 32(16):2767-2789; Huang, “Comparison of teststatistics for the sequential parallel design”, Statistics inBiopharmaceutical Research, 2010, 2(1):42-50; Ivanova, “Optimality,sample size, and power calculations for the sequential parallelcomparison design”, Stat. Med., 2011, 30(23):2793-803; Papakostas,“L-methylfolate as adjunctive therapy for SSRI-resistant majordepression: results of two randomized, double-blind, parallel-sequentialtrials”, Am. J. Psychiatry, 2012, 169(12):1267-1274; Roy, “Anexamination of the efficiency of the sequential parallel design inpsychiatric clinical trials”, Clinical Trials. 2007, 4:309-317; Rybin,“Placebo non-response measure in sequential parallel comparison designstudies”, Stat. Med., 2015, 34(15):2281-2293; Tamura, “An examination ofthe efficiency of the sequential parallel design in psychiatric clinicaltrials”, Clin. Trials. 2007, 4(4):309-317; and Tamura, “Estimation oftreatment effect for the sequential parallel design”, Stat. Med., 2011,30(30):3496-506.

In Panel A, reported here, 14 study sites (13 in US, 1 in Belgium)enrolled participants into the study. The study consisted of fourphases: 1) screening, 2) double-blind treatment (days 1 to 15),comprised of two 1-week periods (Period 1, Period 2), 3) optionalopen-label treatment (days 15 to 74) with tapering of intranasal dosingfrequency, and 4) post-treatment follow-up (8 weeks). Based on priorstudies of ketamine where efficacy was reported after 1-2 doses, theduration of each period in the double-blind phase was 1 week, duringwhich time it was expected that efficacy could be achieved. This designallowed evaluation of the dose(s) needed to proceed to evaluation inphase 3. The purpose of the open-label flexible-dose phase was toevaluate the impact of less frequent dosing on sustaining efficacy.

At the beginning of double-blind Period 1, eligible participants wererandomized (3:1:1:1) to intranasal placebo or esketamine 28, 56, or 84mg, twice weekly (days 1 and 4) based on the first of twocomputer-generated randomization schedules (Period 1 and Period 2).Randomization was balanced by using randomly permuted blocks andstratified by study center. At the end of Period 1, those randomized toplacebo who had moderate-to-severe symptoms (assessed by Quick Inventoryof Depressive Symptomatology-Self Report (Trivedi 2016 and Rush, “The16-item Quick Inventory of Depressive Symptomatology (QIDS) ClinicianRating (QIDS-C) and Self-Report (QIDS-SR): A psychometric evaluation inpatients with chronic major depression”, Biol. Psychiatry, 2003,54(5):573-583) [QIDS-SR₁₆] total score: moderate, 11-16; severe, >16)were re-randomized (1:1:1:1) to intranasal esketamine 28, 56, or 84 mgor placebo, twice weekly (days 8 and 11), while those having mild or nosymptoms continued on placebo. To maintain the blind, all participantscompleted an identical process prior to entry into Period 2, whether ornot they were re-randomized. Regardless of response in the double-blindphase, all participants were eligible to enter the optional open-labelphase. Esketamine (56 mg) was administered on the first day of theopen-label phase (study day 15); subsequent doses could be adjusted(range: 28 to 84 mg) based on investigator's clinical judgment, withadministration twice weekly for first 2 weeks, weekly for next 3 weeks,then every 2 weeks thereafter.

Study Drug and Administration

Study drug was provided in a disposable nasal spray device containing200 μl of solution (i.e., 2 sprays). Each device delivered either 16.14mg esketamine hydrochloride (14 mg esketamine base) per 100-μl spray orplacebo. To maintain the blind, the placebo solution (intranasalsolution of water for injection) had a bittering agent (denatoniumbenzoate) added to simulate the taste of esketamine intranasal solution.As described above, the antidepressant that participants had beenreceiving immediately prior to study entry was continued unchanged.

On each dosing day during the double-blind phase, participantsself-administered 1 spray of study drug (esketamine or placebo) intoeach nostril at 3 time points, each 5 minutes apart. In the open-labelphase, depending on the dose selected, participants self-administered 1spray of esketamine into each nostril at 1, 2, or 3 time points(corresponding to 28, 56, or 84 mg, respectively), each separated by 5minutes.

Efficacy Assessments

Efficacy was assessed with the Montgomery-Asberg Depression Rating Scale(MADRS; Montgomery, “A new depression scale designed to be sensitive tochange”, Br. J. Psychiatry, 1979, 134:382-389; Williams, “Developmentand reliability of a structured interview guide for the MontgomeryAsberg Depression Rating Scale (SIGMA)”, Br. J. Psychiatry, 2008,192(1):52-58) on days 1 (pre-dose and 2 hour post-dose), 2, 8(pre-dose), 9, and 15, using the structured interview guide (SIGMA).See, Williams 2008.

Overall illness severity was assessed on the Clinical Global Impressionof Severity (CGI-S) scale (Guy, “ECDEU Assessment Manual forPsychopharmacology —Revised (DHEW Publ No ADM 76-338)”, Rockville, Md.:U.S. Department of Health, Education, and Welfare, Public HealthService, Alcohol, Drug Abuse, and Mental Health Administration, NIMHPsychopharmacology Research Branch, Division of Extramural ResearchPrograms; 1976, pp 218-222). Participants assessed their severity ofanxiety on the Generalized Anxiety Disorder 7-item (GADS-7) Scale (See,Tables 157 and 158). See, Spitzer, “A brief measure for assessinggeneralized anxiety disorder—the GAD-7”, Arch. Intern. Med., 2006,166(10):1092-1097.

TABLE 157 GAD-7: ANCOVA Analysis of Change from Baseline to Study EndPoint^(a) Esketamine Esketamine Esketamine Placebo 28 mg 56 mg 84 mgPeriod 1 N 33 11 11 12 LS mean (SE) −1.7 (0.88)  −1.5 (1.34) −3.1 (1.34)−5.1 (1.30) LS mean difference −0.21 (1.461) −1.40 (1.478) −3.44 (1.414)from placebo (SE) p-value^(b) 0.558 0.174 0.009 Period 2 N  6 8 9 5 LSmean (SE) 0.4 (1.02) −1.6 (0.87)  1.0 (0.98) −0.9 (1.02) LS meandifference −2.02 (1.089)  0.60 (1.033) −1.25 (1.205) from placebo (SE)p-value^(b) 0.039 0.718 0.156 Periods 1 and 2 Combined p-value 0.1440.360 0.006 ^(a)Change from first day to day 8 in each period; ^(b)Basedon ANCOVA model with treatment, country, and Period 1 baseline value asa covariate; ^(c)Based on ANCOVA model with treatment, country, andPeriod 2 baseline QIDS-SR₁₆ score (moderate or severe), and Period 2baseline value as a covariate.

TABLE 158 CGI-S: ANCOVA Analysis of Change from Baseline to Study EndPoint^(a) Esketamine Esketamine Esketamine Placebo 28 mg 56 mg 84 mgPeriod 1 N 33 11 11 12 Median 5.0 (1, 6) 4.0 (3, 5) 4.0 (1, 5) 4.0 (1,6) (Range) Median Change  0.0 (−3, 2) −1.0 (−2, 1) −1.0 (−3, 0) −0.5(−4, 0) (Range) p-value^(b) 0.028 0.004 0.049 Period 2 N  6 8 9 5 Median5.0 (4, 5) 4.0 (3, 5) 5.0 (4, 6) 4.0 (3, 5) (Range) Median Change −1.0(−1, 0) −1.0 (−2, 0) −1.0 (−2, 0) (Range) p-value^(c) 0.0 (0, 2) 0.0090.050 0.022 Periods 1 and 2 Combined p-value <0.001 <0.001 0.004^(a)Change from first day to day 8 in each period; ^(b)Based on ANCOVAmodel on ranks of change with treatment, country, and Period 1 baselinevalue (unranked) as a covariate; ^(c)Based on ANCOVA model on ranks ofchange with treatment, country, Period 2 baseline QIDS-SR₁₆ score(moderate or severe), and Period 2 baseline value (unranked) as acovariate.

Safety Assessments

Adverse events were monitored throughout the study. Other safetyassessments (i.e., laboratory tests, vital signs, physical examination)were performed at pre-specified time points. Vital signs, the ClinicianAdministered Dissociative States Scale (CADSS; Bremner, “Measurement ofdissociative states with the clinician-administered dissociative statesscale (CADSS)”, J. Traumatic Stress, 1998, 11(1):125-136), and the4-item positive symptom subscale from the Brief Psychiatric Rating Scale(BPRS; Overall, “The Brief Psychiatric Rating Scale. PsychologicalReports”, 1962, 10:799-812) were assessed pre-dose, at 40 minutes, and 2hours post-dose.

Statistical Methods

Efficacy data were analyzed in intent-to-treat (ITT) analysis sets foreach period and phase. The ITT analysis sets included all participantswho received at least 1 dose of study medication during that period orphase and had baseline and at least one post-baseline MADRS total scorewithin that period or phase.

Safety data were analyzed in Period 1, Period 2, double-blind, andopen-label data sets, for all subjects receiving at least 1 dose ofstudy medication.

Efficacy Endpoints and Analyses

The primary efficacy endpoint—change from baseline (pre-dose, day 1 ineach period) to endpoint (day 8 in each period) in MADRS total score—wasanalyzed using the analysis of covariance (ANCOVA) model. For Period 1,the model included treatment and country as factors, and baseline MADRStotal score as covariate. For Period 2, the model included treatment andcountry as factors, Period 2 baseline QIDS-SR₁₆ score (moderate orsevere), and Period 2 baseline MADRS total score as a continuouscovariate.

Given the consistency between Periods 1 and 2 results (Chi 2016),esketamine dose groups were compared to placebo using a combined test onthe weighted test statistics for each period in the double-blindtreatment phase. A dose-response analysis on primary efficacy endpointwas performed using data combined from both periods. The MultipleComparison Procedure-Modelling (MCP-Mod) methodology was performed(Williams 2008; Bretz, “Combining multiple comparisons and modelingtechniques in dose-response studies”, Biometrics, 2005, 61:738-748).

Sample Size Determination

Sample size was determined based on the following differences betweenintranasal esketamine and placebo for mean change from baseline in MADRStotal score: 9-point treatment difference was assumed for Period 1 (day8), 7-point treatment difference for Period 2 (day 15) was assumed forindividuals with a moderate QIDS-SR₁₆ score, and 9-point treatmentdifference for Period 2 (day 15) was assumed for individuals with severeQIDS-SR₁₆ score.

Based on results of an esketamine IV study (Singh 2016), it wasestimated that 40% of placebo participants would have a moderateQIDS-SR₁₆ score and 55%, a severe QIDS-SR₁₆ score at the end of Period 1(day 8 pre-dose). Additional assumptions for the sample size calculationincluded standard deviation of 10, 92.5% power for the combined datafrom day 8 and day 15 (Liu, “Doubly-randomized delayed-start design forenrichment studies with responders or nonresponders”, J. Biopharm.Stat., 2012, 22(4):737-757), overall 1-sided significance level of 0.05,and 5% drop-out rate for Period 1. It was calculated that this panel ofthe doubly-randomized, outcome-based design required 60 individuals tobe randomly assigned to treatment on day 1 in a 3:1:1:1 ratio (30 onplacebo and 10 per intranasal esketamine dose group).

Study Results

Participants

A total of 126 individuals were screened, of which 67 met theeligibility criteria and were randomized. Of 33 participants randomizedto placebo in Period 1, 28 had QIDS-SR₁₆ score ≥11 at the end of Periods and thus were randomly re-assigned to esketamine or placebo in Period2 (FIG. 73). Most randomized participants (63/67, 94%) completed Periodand the 2-week double-blind phase (i.e., Periods and 2 combined 60/67,90%; hereafter termed “completers”. Of these, 57 entered the open-labelphase, with 51 subsequently entering the follow-up phase, of whom 41completed the week 8 follow-up visit.

The treatment groups were similar with respect to demographic andbaseline clinical characteristics (Table 159). Sixty-four percent ofparticipants reported only 1 antidepressant treatment failure in thecurrent episode (in addition to 1 in prior episodes), approximately 22%had 2, and the remainder reported ≥3 antidepressant failures. Of note,39% of participants reported use of atypical antipsychotics as anadjunctive treatment of MDD prior to study entry.

TABLE 159 Demographics and Baseline Characteristics Esketamine Placebo28 mg 56 mg 84 mg Total Parameter N = 33 N = 11 N = 11 N = 12 N = 67Age, years Mean (SD) 44.4 (9.60) 42.1 (10.31) 42.7 (11.23) 49.8 (9.29)44.7 (10.04) Range 21-57 21-53 20-57 32-63 20-63 Sex, n (%) Female 18(54.5) 5 (45.5) 9 (81.8) 6 (50.0) 38 (56.7) Male 15 (45.5) 6 (54.5) 2(18.2) 6 (50.0) 29 (43.3) Race, n (%) White 24 (72.7) 7 (63.6) 6 (54.5)11 (91.7) 48 (71.6) Black or African American 9 (27.3) 4 (36.4) 4 (36.4)1 (8.3) 18 (26.9) American Indian or Alaska native 0 0 1 (9.1) 0 1 (1.5)BMI, kg/m² Mean (SD) 29.7 (6.00) 29.0 (6.18) 30.1 (8.30) 30.4 (8.47)29.8 (6.77) Range 17-49 23-44 19-45 21-49 17-49 MADRS Total Score Mean(SD) 35.0 (5.18) 31.3 (3.80) 33.2 (6.26) 35.0 (4.22) 34.1 (5.11) Range25-45 26-37 23-46 27-41 23-46 IDS-C₃₀ Total Score Category, n (%)Moderate (34-39) 10 (30.3) 4 (36.4) 3 (27.3) 3 (25.5) 20 (29.9) Severe(40-48) 15 (45.5) 7 (63.6) 6 (54.5) 9 (75.0) 37 (55.2) Very severe (≥49)8 (24.2) 0 2 (18.2) 0 10 (14.9) Mean (SD) 43.9 (6.81) 41.1 (4.25) 42.3(6.72) 42.5 (4.23) 42.9 (6.02) Range 35-59 35-48 34-57 34-48 34-59Duration of Current Episode (wks) Mean (SD) 65.2 (79.93) 56.1 (39.28)39.9 (21.82) 66.6 (51.54) 59.8 (63.5) Range  12-302  14-122 10-75 18-162  10-302 Number of Major Depressive Episodes <3 4 (12.1) 3 (33.3)2 (20.0) 2 (18.2) 11 (17.5) ≥3 29 (87.9) 6 (66.7) 8 (80.0) 9 (81.8) 52(82.5) Number of Antidepressants in Current Episode of Major Depression1 21 (63.6) 6 (54.5) 8 (72.7) 8 (66.7) 43 (64.2) 2 7 (21.2) 4 (36.4) 2(18.2) 2 (16.7) 15 (22.4) ≥3 5 (15.2) 1 (9.1) 1 (9.1) 2 (16.7) 9 (13.4)

Efficacy Results

Mean MADRS total score decreased from baseline to day 8 in Period E andfrom day 8 to day 15 in Period 2 in all groups, with greater improvementin all esketamine dose groups compared to placebo (LS mean differenceranging from −5.0 to −10.5 in Period 1 and from −3.1 to −6.9 in Period2; Table 160). Change from baseline in MADRS total score was greater inall 3 esketamine groups than in the placebo group after 1 week oftreatment (p=0.02, p=0.001, and p<0.001 for esketamine 28 mg, 56 mg and84 mg, respectively); the ascending dose-response relationship wassignificant (p<0.001). Response was rapid in onset (FIGS. 74A and 74B;FIGS. 76A and 76B) and appeared to increase over time during repeateddosing, as evidenced by a decrease in mean MADRS total score over theopen-label phase (mean [SE] change from open-label baseline to day 74:−7.2 [1.84]) despite reduced dosing frequency in the open-label phase.In addition, improvement in mean MADRS ratings persisted over the 8-weekfollow-up phase (without additional esketamine doses) in thoseparticipants who remained in the study (FIG. 75).

TABLE 160 MADRS Total Score: Change from Baseline to 2 Hours, 24 Hours,and to Period Endpoint Esketamine Esketamine Esketamine Placebo 28 mg 56mg 84 mg Period 1 N 33  11    11    12    Mean (SD) MADRS total score at35.0 (5.18) 31.3 (3.80) 33.2 (6.26) 35.0 (4.22) baseline Change at 2hours LS mean change (SE) −9.7 (1.76) −16.4 (2.76) −14.3 (2.70) −17.6(2.60) LS mean difference placebo (SE) −6.7 (3.03) −4.6 (2.96) −7.9(2.84) p-value 0.02 0.06  0.003 Responders, n (%) 6 (18.2) 6 (54.5) 4(36.4) 7 (58.3) Remitters, n (%) 1 (3.0) 3 (27.3) 2 (18.2) 3 (25.0)Change at 24 hours LS mean change (SE) −5.7 (1.79) −14.8 (2.80) −15.7(2.74) −16.4 (2.64) LS mean difference placebo (SE) −9.1 (3.08) −10.0(3.00) −10.7 (2.88) p-value  0.002 <0.001 <0.001 Responders, n (%) 1(3.0) 4 (36.4) 3 (27.3) 5 (41.7) Remitters, n (%) 0 4 (36.4) 2 (18.2) 3(25.0) Change at study period endpoint LS mean change (SE) −4.9 (1.74)−9.8 (2.72) −12.4 (2.66) −15.3 (2.56) LS mean difference placebo (SE)−5.0 (2.99) −7.6 (2.91) −10.5 (2.79) p-value 0.05  0.006 <0.001Responders, n (%) 2 (6.1) 1 (9.1) 2 (18.2) 5 (41.7) Remitters, n (%) 1(3.0) 1 (9.1) 1 (9.1) 3 (25.0) Period 2* N 6 8   9   5   Mean (SD) MADRStotal score at 29.3 (5.79) 31.3 (7.09) 34.9 (6.13) 30.4 (4.67) baselineChange at 2 hours LS mean change (SE) −6.8 (3.74) −10.3 (3.18) −11.7(3.22) −11.6 (3.44) LS mean difference placebo (SE) −3.5 (3.82) −4.9(3.92) −4.9 (4.36) p-value 0.18 0.11 0.14 Responders, n (%) 1 (16.7) 1(12.5) 2 (22.2) 2 (40.0) Remitters, n (%) 1 (16.7) 1 (12.5) 0   2 (40.0)Change at 24 hours LS mean change (SE) −4.1 (4.09) −8.9 (3.48) −10.2(3.52) −11.6 (3.76) LS mean difference placebo (SE) −4.8 (4.18) −6.1(4.29) −7.5 (4.77) p-value 0.13 0.09 0.07 Responders, n (%) 0 0   1(11.1) 2 (40.0) Remitters, n (%) 0 0   0   1 (20.0) Change at studyperiod endpoint LS mean change (SE) −4.5 (2.92) −7.6 (2.49) −8.9 (2.51)−11.4 (2.68) LS mean difference placebo (SE) −3.1 (2.99) −4.4 (3.06)−6.9 (3.41) p-value 0.15 0.08 0.03 Responders, n (%) 0 1 (12.5) 0   1(20.0) Remitters, n (%) 0 1 (12.5) 0   1 (20.0) Period 1 and Period 2Combined Mean difference placebo (SE) −4.2 (2.09) −6.3 (2.07) −9.0(2.13) 90% CI for mean difference vs. −7.67, −0.79 −9.71, −2.88 −12.53,−5.52 placebo Test statistic −2.02  −3.04  −4.24  p-value 0.02  0.001<0.001 *The study samples reported here for Period 2 include only theplacebo nonresponsive participants re-randomized following Period 1.

For completers who received 2 weeks of the same treatment in thedouble-blind phase, mean decrease in MADRS total score was greater ineach esketamine dose group as compared with placebo at day 15, with themagnitude of decrease directly related to dose (treatment differencesrelative to placebo of −12.5, −8.3, and −6.0 for esketamine 84 mg, 56mg, and 28 mg, respectively). Efficacy appeared to be better sustainedbetween drug administrations with the 2 higher doses (FIG. 73).

Among those who received the same treatment for bath periods andcompleted the double-blind phase, the proportion of responders (definedas ≥50% improvement from baseline in MADRS total score) in eachesketamine dose group was numerically higher than in the placebo groupat the Period 2 endpoint (28 mg: 37.5% [3/8], 56 mg: 36.4% [4/11], 84mg: 50.0% [5/10], placebo 10% [1/10]). A similar trend for remission(defined as MADRS total score ≤10) was observed across groups. Amongcompleters who received the same treatment in both periods, moreparticipants treated with the 2 higher esketamine doses, as compared toplacebo, remitted after 2 weeks of treatment (12.5%, 27.3%, and 40.0% inthe 28 mg, 56 mg and 84 mg groups, respectively, and 10.0%, in theplacebo group). Response and remission rates at the end of theopen-label and follow-up phases are presented by type of treatment inthe double-blind and open-label phases in Table 161.

TABLE 161 Response, Remission, and Relapse Rates for Participants whoCompleted the Open-Label and Follow-up Phases Placebo/ Placebo/Esketamine/ Placebo/OL Esketamine/OL Esketamine/OL Esketamine EsketamineEsketamine Total N = 10 N = 20 N = 27 N = 57 Response Rate OL endpoint -day 74, n 6 10 18 34 ≥50% improvement, n (%) 6 (100)  5 (50.0) 11 (61.1)22 (64.7) Week 8 (Follow-up), n 7 12 22 41 ≥50% improvement, n (%) 5(71.4) 3 (25.0) 15 (68.2) 23 (56.1) Remission Rate OL endpoint - day 74,n 6 10 18 34 No, n (%) 4 (66.7) 6 (60.0) 13 (72.2) 23 (67.6) Yes, n (%)2 (33.3) 4 (40.0)  5 (27.8) 11 (32.4) Week 8 (Follow-up), n 7 12 22 41No, n (%) 3 (42.9) 9 (75.0) 12 (54.5) 24 (58.5) Yes, n (%) 4 (57.1) 3(25.0) 10 (45.5) 17 (41.5) Percentages calculated with the number ofparticipants per a visit as denominator; percentage change is calculatedbased on Period 1 baseline; Response: MADRS total score ≥50%; Remission:MADRS total score ≤10. The follow-up phase includes data from 7 subjectsenrolled under the original version of the protocol in whichparticipants received 2 weeks of study drug during the open-label phaseof the study and data from 50 subjects enrolled under a protocolamendment in which participants received up to 9 weeks of study drugduring the open-label phase of the study.

Safety Results

Three of 56 (5%) esketamine-treated participants during the double-blindphase (compared to 0 on placebo) and 1 of 57 (2%) during the open-labelphase had adverse events leading to discontinuation of study drug (1event each of syncope, headache, dissociative syndrome, and ectopicpregnancy). During the double-blind phase, the 3 most commontreatment-emergent adverse events observed among esketamine-treatedparticipants were dizziness, headache, and perceptualchanges/dissociative symptoms; the frequency of each was >2-fold higherfor esketamine than for placebo (Table 162). A dose-response trend wasnoted for dizziness and nausea, but not for other adverse events. Thetype and frequency of adverse events reported in the open-label phasewere similar to those in the double-blind phase; events reportedfor >10% of open-label participants included dizziness (38.6%),dysgeusia (22.8%), nausea (15.8%), headache (14.0%), and sedation(10.5%). Overall, 24.6% (14/57) of participants reported transientdissociative symptoms. The majority of adverse events occurring ondosing days were transient and either mild or moderate in severity. Nodeath was reported.

TABLE 162 Summary of Most Frequently Reported^(a) Treatment-EmergentAdverse Events (Double-Blind Safety Analysis Data Set) Number (%) ofParticipants Esketamine Placebo 28 mg 56 mg 84 mg Total Preferred Term N= 33 N = 19 N = 20 N = 17 N = 56 Total with 18 (55) 11 (58) 16 (80) 15(88) 42 (75) events Dizziness 1 (3) 4 (21) 8 (40) 8 (47) 20 (36)Headache 3 (9) 6 (32) 3 (15) 3 (18) 12 (21) Dissociation^(b,c) 1 (3) 0 7(35) 4 (24) 11 (20) Dysgeusia  7 (21) 2 (11) 3 (15) 5 (29) 10 (18)Nausea 3 (9) 2 (11) 4 (20) 4 (24) 10 (18) Dissociative 0 2 (11) 1 (5) 4(24) 7 (13) disorder^(b,c) Hypoesthesia 0 1 (5) 4 (20) 2 (12) 7 (13)oral Vertigo 0 2 (11) 1 (5) 1 (6) 4 (7) Sedation 0 1 (5) 2 (10) 1 (6) 4(7) Feeling 0 2 (11) 1 (5) 1 (6) 4 (7) abnormal Nasal 3 (9) 0 2 (10) 1(6) 3 (5) discomfort Hypertension 2 (6) 0 2 (10) 1 (6) 3 (5)Oropharyngeal 2 (6) 0 1 (5) 2 (12) 3 (5) pain Throat 0 1 (5) 0 2 (12) 3(5) irritation Vision blurred 0 0 0 2 (12) 2 (4) Insomnia 1 (3) 0 2 (10)0 2 (4) Tunnel vision 0 0 0 2 (12) 2 (4) Hypersomnia 0 2 (11) 0 0 2 (4)Polyuria 0 0 2 (10) 0 2 (4) ^(a)Defined as ≥10% of participants in anyesketamine dose group. Events presented in descending order in the totalesketamine (combined doses) group. ^(b)Participants reported eitherdissociative reaction or dissociative symptoms and, depending on theverbatim term used these events were coded as dissociative disorder ordissociative symptoms, respectively. ^(c)All adverse events coded todissociation or dissociative disorder resolved on the same day asdosing.

Most of the esketamine-treated participants manifested transientelevations in blood pressure (maximum mean change: systolic, 19.0 mmHg;diastolic, 10.3 mmHg) and heart rate (maximum mean change: 9.4 bpm) ondosing days. Maximum blood pressure values were observed in most casesat 10 or 40 minutes post-dose (systolic: 199 mmHg; diastolic: 115 mmHg);elevated values typically returned to the normal range by 2 hourspost-dose (FIGS. 77 and 78). A dose effect was not observed for heartrate, although the greatest mean increases from baseline during bothperiods were observed in the 84 mg esketamine group.

Perceptual changes/dissociative symptoms, as measured by the CADSS,began shortly after the start of intranasal dosing, peaked around 30-40minutes, and resolved by 2 hours (FIG. 79). Perceptualchanges/dissociative symptoms attenuated in all dose groups withrepeated dosing.

No participant manifested symptoms suggestive of psychosis based on theBPRS-positive assessment.

Discussion

A significant and clinically meaningful treatment effect (versusplacebo) with 28 mg, 56 mg, and 84 mg doses of esketamine was observed,as evidenced by change in MADRS total score, with a significantrelationship between esketamine dose and antidepressant responseobserved after 1 week of treatment. Duration of efficacy appearedshorter with the 28 mg dose administered twice weekly. Results from theopen-label phase suggest that improvement in depressive symptoms can besustained with lower frequency (weekly/every 2 weeks) of esketamineadministration. Of note, the size of the medication-placebo differencewas substantial from baseline to one week, and was larger than the meandifference from placebo seen at 6-8 weeks in antidepressant studies inthe FDA database (Khan, “Has the rising placebo response impactedantidepressant clinical trial outcome? Data from the US Food and DrugAdministration 1987-2013”, World Psychiatry. 2017, 16(2):181-192). Themajority of participants maintained improvement over the 2-monthfollow-up phase.

Of note, the 56 and 84 mg intranasal doses of esketamine produce plasmaesketamine levels that are in the pharmacokinetic range achieved by IVesketamine at 0.2 mg/kg, which produced a similar clinical outcome asreported for ketamine 0.5 mg/kg IV (consistent with higher affinity forNMDA receptors relative to arketamine (White, “Comparative pharmacologyof the ketamine isomers. Studies in volunteers”, Br. J. Anaesth., 1985,57(2):197-2030). See, Singh 2016.

In this first study of intranasal esketamine for TRD, efficacy andsafety were compared to placebo using a double-blind, doubly-randomized,delayed-start design (Chi 2016), allowing for a smaller sample size toassess efficacy, dose-response, and safety than a standardparallel-group design, while preserving a low chance of type 2 error inorder not to miss the efficacy signal. The key aim of the design was toonly include placebo participants from Period 1 who required treatmentin Period 2 and to re-randomize them to receive 1 of 3 intranasalesketamine doses or intranasal placebo. At the end of the trial,efficacy data from both randomizations (day 1 and day 8) were combinedin an integrated analysis. As the re-randomized placebo non-responderswere expected to have a lower placebo response, this approach was usedto mitigate high placebo responses observed in psychiatric clinicaltrials (Chi 2016). The consistency in results obtained from the Period 1and Period 2 samples support their combination using weights (Chi 2016),although caution is required in interpretation due to the small samplesize.

In general, the esketamine doses evaluated in this study (28, 56, and 84mg) appeared safe, with no new or unexpected safety concerns observed.Analysis of perceptual change symptoms (measured by CADSS assessment)suggests onset shortly after initiation of esketamine and resolution by2 hours after administration. These symptoms were dose-dependent andattenuated with repeated administration. In contrast, antidepressantefficacy did not attenuate across administrations.

Overall, transient increases in blood pressure post-dose, particularlyincreases in systolic blood pressure, support an increase in cardiacoutput as the underlying mechanism, consistent with previous reports forketamine (Murrough 2013).

Generalizability of study findings is limited by small sample size andenrollment criteria that excluded individuals with a history ofpsychotic symptoms, substance/alcohol use disorders, recent use ofcannabis, or significant medical comorbidities. Also excluded wereindividuals having current suicidal ideation with intent, a group thatwas evaluated in a separate, study (Murrough 2013). Difficulty blindingesketamine, despite adding a bittering agent to placebo to mimic thetaste of esketamine, is another limitation.

Conclusions

In summary, intranasal esketamine administered at doses of 28, 56, and84 mg appeared efficacious in treating TRD. There was evidence of robustand durable efficacy in the double-blind treatment phase (56 and 84 mg).Improvement in depressive symptoms persisted over the open-label phase,despite reduced dosing frequency, and for up to 2 months after cessationof esketamine dosing.

Example 8: Validated Pharmacokinetic Method

This example provides an LC-MS/MS method for the determination ofketamine and norketamine in sodium heparin human plasma usingketamine-d₄ and norketamine-d₄ as the respective internal standards(IS).

All the data presented herein met the method validation acceptancecriteria defined in the validation protocol and fulfilled therequirements and recommendations in the FDA guidance for bioanalyticalmethod validations for the parameters tested.

In summary, this method has been validated for the determination ofketamine and norketamine in sodium heparin human plasma. Based on a 25μL sample volume, the lower limit of quantitation (LLOQ) is 0.500/0.500ng/mL for ketamine/norketamine. The dynamic range of the method is0.500/0.500-500/500 ng/mL for ketamine/norketamine. The re-injectedsamples were reproduble at room temperature for at least 161.5 hoursafter the initial injection. There was no significant injectioncarryover detected.

The validation study successfully evaluated intra-run and inter-runaccuracy and precision, selectivity, sensitivity, linearity, recovery,matrix effect, maximum batch-size evaluation, reinjectionreproducibility, and carry-aver evaluation. This method was determinedto be suitable for the determination of ketamine and norketamine inhuman plasma using solid phase extraction (SPE) automation. See, Table163.

TABLE 163 Validation Summary for the Determination of Ketamine andNorketamine Method description The method is an LC-MS/MS method for thedetermination of ketamine and norketamine in sodium heparin human plasmausing ketamine-d₄ and norketamine-d₄ as the respective internalstandards (IS). Ketamine, norketamine, and the internal standards wereextracted from human plasma using automated solid phase extraction.Reversed-phase HPLC separation was achieved with a Phenomenex SynergiPolar-RP column, (50 × 2.0 mm, 4 micron). MS/MS detection was set atmass transitions of m/z 238.1→125.0 for ketamine, m/z 224.1→125.0 fornorketamine, m/z 242.1→129.0 for ketamine-d₄ (IS), and m/z 228.1→129.0for norketamine-d₄ (IS) in TIS positive mode. Sample volume 25 μLRegression Linear Regression Weighting factor 1/x² Dynamic range0.500-500 ng/mL for ketamine 0.500-500 ng/mL for norketamine QCconcentrations 0.500 ng/mL (LLOQ), 1.50 ng/mL, 80.0 ng/mL, 375 ng/mL forketamine 0.500 ng/mL (LLOQ), 1.50 ng/mL, 80.0 ng/mL, 375 ng/mL fornorketamine Analytes Ketamine Norketamine Internal standards Ketamine-d₄Norketamine-d₄ Linearity R² ≥ 0.9986 R² ≥ 0.9979 Lower limit ofquantitation 0.500 ng/mL 0.500 ng/mL (LLOQ) Average recovery of theAnalyte 88.6 88.5 (%) Average recovery of the IS (%) Per BIO-201guidelines, if a stable isotope labeled IS was used, the recoveryestablished for the unlabeled analyte will suffice and the recovery forthe stable isotope labeled IS will not be required. QC Levels LLOQ Low,Mid, High LLOQ Low, Mid, High QC Intra-run Intra-run 1 7.1 1.0 to 3.17.4 2.4 to 5.7 precision range Intra-run 2 4.7 1.6 to 3.1 5.3 2.7 to 3.6(% CV) Intra-run 3 6.5 1.3 to 1.8 4.3 1.3 to 3.5 QC Intra-run Intra-run1 1.0 −2.0 to 0.8 −2.0 0.0 to 1.1 accuracy range Intra-run 2 7.8 −1.3 to2.1 2.0 −4.0 to 1.6 (% Bias) Intra-run 3 −2.0 2.7 to 2.3 0.2 0.0 to 1.9QC Inter-run precision range 7.1 1.8 to 2.7 5.7 2.2 to 4.6 (% CV) QCInter-run accuracy range 2.2 −2.0 to 1.0 0.0 −1.3 to 1.3 (% Bias) QCsample bench-top stability 68.5 hours at room temp Stock solutionstability 629 days at −20° C. and 6 hours at room temperature underwhite light for ketamine and norketamine stock solutions. 610 days at−20° C. for ketamine/norketamine spike solutions Processed samplestability 146.5 hours at room temperature Reinjection reproducibility161.5 hours at room temperature QC sample freeze/thaw stability 3 freeze(−20° C.)/thaw (ice-water bath) cycles 3 freeze (−20° C.)/thaw (roomtemperature) cycles Dilution integrity 7500/7500 ng/mL diluted 20-foldfor ketamine/norketamine QC sample long-term storage 1552 days at −20°C. stability Matrix Effect IS-normalized Matrix factor = 1.03 ± 0.03 at1.50 ng/mL with % CV = 2.9% for ketamine IS-normalized Matrix factor =1.02 ± 0.06 at 375 ng/mL with % CV = 5.9% for ketamine IS-normalizedMatrix factor = 1.05 ± 0.03 at 1.50 ng/mL with % CV = 2.9% fornorketamine IS-normalized Matrix factor = 1.04 ± 0.05 at 375 ng/mL with% CV = 4.8% for norketamine Hemolysis The hemolysis evaluation met theacceptance criteria. LLOQ Selectivity The LLOQ selectivity samplesprepared in human plasma were within acceptance criteria (the accuracywas within ±20.0% for five out of six lots of plasma for ketamine andwithin 20.0% for all six lots for norketamine). Blank Selectivity Theblank selectivity samples were within acceptance criteria. All 6 blanksamples at the retention time of the analytes were within 20.0% of themean analyte peak area of the acceptable LLOQ selectivity samples andall 6 blank samples at the retention time of the IS were within 5.0% ofthe mean IS peak area of the acceptable LLOQ selectivity samples. BatchSize 214 samples Injection Carryover No significant carryover wasobserved in any of the double blank samples that were evaluated forinjection carryover. Whole Blood Stability 120 minutes at roomtemperature and in an ice-water bath (0-4° C.) Inter-conversion Theinter-conversion from ketamine to norketamine or vice versa was ≤5%.Interference There was no interference detected from either of theanalytes on the internal standards. Nor was there any interferencedetected from dehydronorketamine on ketamine and norketamine. StockSolution Evaluation No significant difference was found between thechiral s-ketamine and between S-isomer and Racemic racemic solutions.Compound for Ketamine Stock Solution Evaluation No significantdifference was found between the chiral s-norketamine between S-isomerand Racemic and racemic solutions. Compound for Norketamine S-KetamineQC sample bench- 18 hours at room temperature top stability S-KetamineQC sample 3 freeze (−20° C.)/thaw (room temperature) cycles freeze/thawstability S-Ketamine QC sample long- 707 days at −20° C. term storagestability

1. Experimental 1.1. Bioanalytical Method

This bioanalytical method for the determination of ketamine andnorketamine in sodium heparin human plasma using SPE automation wasvalidated.

1.2. Equipment

-   -   LC-MS/MS, Sciex API 4000 (System Nos. 220 and 222) with Shimadzu        HPLC (System Nos. 219 and 223) pump and autosampler    -   Analyst Data Acquisition Software (1.4.2)    -   Column: Phenomenex Synergi Polar-RP, 50×2.0 mm, 4 micron    -   Switch Valve, Valco Instruments    -   ELGA Water Purification System (System 56-2), Model PL5231    -   Analytical Balance, Sartorius CP22P, capable of weighing 0.00001        g    -   Micro Balance, Mettler Toledo MX5, capable of weighing 0.000001        g    -   Centrifuge, Beckman GS-6R, (System No. 694)    -   Pulse Vortex Mixer, Glas Col® Cat No. 099A PVM12    -   Titer Plate Shaker, Thermo Scientific, Barnstead/Lab-Line, Model        4625    -   1.40 mL Non-coded Pushcap tubes U-bottom, Part No. MP32022, NOVA    -   Microliter plate, Deep Polypropylene Square Well/Conical Bottom,        2.0 mL, Microliter Analytical Supplies, Inc., Part No. 07-7400    -   96 Position Square Well, Pierceable Cover, EVA, Microliter        Analytical Supplies, Inc., Product No. 07-0017N    -   SPE Dry™ 96 system, Biotage    -   Tomtec Automation System, Tomtec Quadra 3 (System No. 114)    -   Oasis MCX 96-well SPE plate 30 μm, 10 mg

1.3. Standards and Reagents

-   -   Ketamine Hydrochloride (U.S. Pharmacopeia, Purity 99.9% (a salt        conversion factor of 237.73/274.19 was applied to the purity        (99.9%) during use)    -   Ketamine-d₄ Hydrochloride (Cerilliant, 100.0±0.5 μg/mL in        methanol (as freebase))    -   Norketamine Hydrochloride (Tocris Bioscience, Purity 100% (a        salt conversion factor of 223.70/260.16 was applied to the        purity (100%) during use.)    -   (±)-Norketamine-d₄ Hydrochloride (Cerilliant, 100.0±0.5 μg/mL in        methanol (as freebase)    -   Water, purified    -   Methanol (Fisher Scientific, HPLC grade)    -   Ammonium Formate (ACROS, GR grade)    -   Ammonium Acetate (Fisher Scientific, ACS reagent grade)    -   Ammonium Hydroxide, 28-30% (Fisher Scientific, ACS reagent        grade)    -   Formic Acid (ACROS, ACS reagent grade

1.4. Biological Matrix

Blank sodium heparin human plasma was purchased from Bioreclamation IVT.The pooled plasma was used to prepare the calibration standards, QCsamples, validation samples, blanks, and double blanks. The plasma(pooled and individual lots) was stored at −20° C.

1.5. Concentrations of Working Standards

The working standards were freshly prepared on each day of analysis inpooled blank plasma, at the concentration levels listed in Table 164.

TABLE 164 Working Standard Concentrations Calibration StandardKetamine/Norketamine Concentration, ng/mL STD 1 0.500/0.500 STD 21.00/1.00 STD 3 2.50/2.50 STD 4 50.0/50.0 STD 5 100/100 STD 6 250/250STD 7 400/400 STD 7 500/500

1.6. Concentrations of QC Samples

The QC samples were prepared in pooled human plasma at the concentrationlevels listed in Table 165. The QC samples were stored at −20° C.

TABLE 165 QC Sample Concentrations Quality ControlKetamine/Norketamine^(b) Concentration, ng/mL LLOQ 0.500/0.500 Low QC1.50/1.50 Mid QC 80.0/80.0 High QC 375/375

2. Data Evaluation

Retention time and peak area were determined by Analyst® DataAcquisition/Processing Software (Version 1.4.2). Analyte concentrationswere obtained from a calibration curve constructed by plotting the peakarea ratio versus the concentration using Watson LIMS (Version 7.3).Watson LIMS and Microsoft Office Excel were used for statisticalcalculations. When Office Excel was used the calculations were 100%audited. Concentrations were calculated using linear regressionaccording to the following equation:

y=ax+b

Where:

-   -   y=peak area ratio of analyte/internal standard    -   a=slope of the corresponding standard curve    -   x=concentration of analyte (ng/mL)    -   b=intercept of the corresponding standard curve    -   Use 1/x² as weighting factor

For calculation of accuracy and precision, the following formulas wereused:

Accuracy:

${\%{Bias}} = {\frac{{Mean}{measured}{{conc}.{- {Nominal}}}{{conc}.}}{{Nominal}{{conc}.}} \times 100}$

Precision:

${\%{CV}} = {\frac{{Standard}{Deviation}({SD})}{{Mean}{measured}{{conc}.}} \times 100}$

Precision and accuracy were reported to one decimal place. Allconcentration data was reported to three significant figures.

3. Matrix Selectivity

Selectivity is defined as the ability of a chromatographic method tomeasure a response from the analyte without interference from thebiological matrix. This was accomplished by evaluating six individuallots of human plasma prepared as blank and at the lower limit ofquantitation (LLOQ, 0.500 ng/mL).

3.1. Evaluation Based on LLOQ Samples

The LLOQ selectivity samples were acceptable if the accuracy was within±20.0% for at least 5 of the 6 samples and the precision has to be≤20.0% for all the samples.

3.2. Evaluation Based on Blank Samples

The peak areas of the analyte in the six blanks were compared with themean peak area of the analyte in the LLOQ selectivity samples. Theevaluation was acceptable if the peak area in 5 of the 6 blanks at theretention time of the analyte were within ≤20.0% of the mean peak areaof the analyte of the LLOQ selectivity samples. In addition, the peakarea in 5 of the 6 blanks at the retention time of the IS must be within≤5.0% of the mean peak area of the IS of the LLOQ selectivity samples.The results for ketamine and norketamine met the acceptance criteria.

The retention times of ketamine and ketamine-d₄ (IS) were approximately2.3 minutes. The retention times of norketamine and norketamine-d₄ (IS)were approximately 2.0 minutes.

3.3. Injection Carry-Over

The purpose of the injection carryover test is to evaluate the extent ofcarryover of the analyte of interest from one sample to the next in eachanalytical run. A double blank sample was injected following the highstandard from the set of calibrators during the validation runs. Theinjection carryover of the analyte was less than 20% of the peak area ofthe LLOQ (Standard 1) for all double blank samples, thus meeting theacceptance criteria. In addition, the peak area of the IS was 0.0% ofthe mean IS peak area from accepted batch calibration standards and QCsamples, well within the 5.0% acceptance criteria.

3.4. Matrix Effect

The matrix effect is defined as the suppression or enhancement ofionization of analytes by the presence of matrix components in thebiological samples. See, e.g., C. T. Viswanathan, “QuantitativeBioanalytical Methods Validation and Implementation: Best Practices forChromatographic and Ligand Binding Assays,” Pharmaceutical Research,Vol. 24, No. 10, October 2007, p. 1969. The matrix effect was evaluatedby extracting single replicates of six lots of blank human plasma andspiking each lot at the Low and High QC concentration levels (1.50 ng/mLand 375 ng/mL) post extraction. The area ratios of the six lots ofpost-extraction spiked plasma samples were compared to the mean arearatio obtained from three replicates of the neat solution prepared atthe same concentration level in purified water.

The IS-normalized matrix factor was calculated according to thefollowing formula:

${IS}‐{{{normalized}{Matrix}{Factor}} = \text{ }\frac{{Peak}{Area}{Ratio}{in}{Presence}{of}{Matrix}}{{Mean}{Peak}{Area}{Ration}{}{in}{Absence}{of}{Matrix}}}$

The variability in the IS-normalized matrix factors (% CV) of the 6 lotsof plasma samples was ≤15%, which was acceptable.

The quantification range was 0.5 to 500 ng/mL for both esketamine andnoresketamine. All the assay acceptance criteria were met.

3.5. Back-Calculated Concentrations of Calibration Standards

Back-calculated concentrations of the calibration standards for ketamineand norketamine were determined. The mean back-calculated concentrationsdid not differ by more than 15% from the nominal concentrations (20.0%at the LLOQ) and the % CV for each concentration level was no more than15.0% (20.0% at the LLOQ).

3.6. Regression Model

The linearity of the method was evaluated at a linear range of0.500/0.500-500/500 ng/mL for ketamine/norketamine in human plasma.Linear regression (with a weighting factor of 1/x2) was used to producethe best fit for the concentration-detector response relationship forketamine and norketamine in human plasma. All calibration curves forketamine and norketamine had a coefficient of determination (R²)≥0.98,which met acceptance.

3.7. Sensitivity

The validation was conducted with a target LLOQ of 0.500 ng/mL forketamine and norketamine in human plasma. To evaluate the sensitivity,six QC samples prepared at the LLOQ were analyzed during threeindividual batch runs as part of the intra-run and inter-run accuracyand precision for the method. The concentrations were calculated withthe calibration curve. The results demonstrated that the method met theacceptance criteria for sensitivity (accuracy within ±20.0% and % CV nomore than 20.0%).

Therefore, the method was sensitive enough to determine ketamine andnorketamine plasma at a concentration of 0.500 ng/mL.

3.8. Intra-Run and Inter-Run Accuracy and Precision

The intra-run and inter-run accuracy and precision of the method wereinvestigated at four different QC concentration levels (0.500 ng/mL(LLOQ), 1.50 ng/mL, 80.0 ng/mL, and 375 ng/mL). The results demonstratedthat the intra-run and inter-run precision and accuracy of the methodmet the acceptance criteria (accuracy within ±15.0% (within ±20.0% forLLOQ) and % CV no more than 15.0% (20.0% for LLOQ)).

3.9. Recovery

The recovery of the sample preparation was evaluated by comparing themean area ratio of the QC samples with the mean area ratio of directlyspiked ketamine/norketamine samples (at the same concentrations) inextracted pooled plasma. Recoveries were calculated according to thefollowing formula:

${\%{Recovery}} = {\frac{{mean}{area}{ratio}{}{of}{Extracted}{QC}}{{{mean}{area}{ratio}{}{of}{Un}} - {{extracted}{sample}}} \times 100}$

Recovery was determined for ketamine and norketamine at three QCconcentration levels (Low, Mid, and High). For each concentration, sixmeasurements were performed. The variability (% CV) of the peak arearatio for each QC level should be ≤15%. The results were acceptable. PerBIO-201 guidelines, if a stable isotope labeled IS was used, therecovery established for the unlabeled analyte will suffice and therecovery for the stable isotope labeled IS will not be required.

3.10. Reinjection Reproducibility

To assess the reinjection reproducibility, an analyte batch containing astandard curve and QC samples was reinjected after being kept at roomtemperature for 161.5 hours. The calibration standards and QC samples(Low, Mid, and High) met the general batch run acceptance criteria,demonstrating that samples may be reinjected up to 161.5 hours after theinitial injection.

3.11. Batch Size Evaluation

During validation, analytical run No. 3 was used to mimic the batch sizefor a sample analysis run. A total of 214 samples were run in the batch,which included both a standard curve and intra-run QC samples. Thecalibration standards and the intra-run QC samples met the general batchacceptance criteria for a sample analysis run.

Example 9: Pharmacokinetic Studies

The primary objective of this study was to evaluate the pharmacokinetics(PK) of intranasally-administered esketamine in healthy subjects.

1. Methods 1.1. Overview of Study Design 1.1.1. Overall Design

This was an open-label, single-center study. The subjects were healthyCaucasian men and women, 20 to 55 years of age, inclusive. As describedin Example 1, esketamine was supplied as a clear, colorless intranasalsolution of esketamine hydrochloride (16.14% weight/volume [w/v];equivalent to 14% w/v of esketamine base) in a nasal spray pump. Thesolution consisted of:

161.4 mg/mL esketamine hydrochloride;

0.12 mg/mL ethylenediaminetetraacetic acid (EDTA);

1.5 mg/mL citric acid;

at a pH of 4.5 in water for injection.

The solution is provided in a nasal spray pump, which delivered 16.14 mgesketamine hydrochloride (14 mg esketamine base) per 100-μL spray.

All subjects self-administered each of the 3 different single-doseregimens of intranasal esketamine (Treatments A, B, and C), over 3treatment periods (i.e., 1 treatment per period) in an open-labelmanner, under the direct supervision of the investigator or designee.

-   -   Treatment A: 1 spray of 14% esketamine solution in each nostril        at Time 0 (total dose 28 mg);    -   Treatment B: 1 spray of 14% esketamine solution in each nostril        at Time 0 and repeated after 5 minutes (total dose 56 mg);    -   Treatment C: 1 spray of 14% esketamine solution in each nostril        at Time 0 and repeated every 5 minutes ×2 (total dose 84 mg).

The subjects were randomly assigned to receive Treatment A and TreatmentB in the first 2 periods (i.e., Treatment A in Period 1 and Treatment Bin Period 2, or the reverse order). All subjects received Treatment C inPeriod 3 (Table 166). The regimens differed in the number of sprays toachieve the total dose and the total esketamine dose administered. Awashout period of 5 to 14 days separated each intranasal esketaminetreatment regimen.

TABLE 166 Treatment Sequences for Subjects Sequence Period 1 Period 2Period 3 1 A B C 2 B A C A: 1 spray of 14% esketamine solution in eachnostril at Time 0 (total dose 28 mg) B: 1 spray of 14% esketaminesolution in each nostril at Time 0 and repeated in 5 minutes (total dose56 mg) C: 1 spray of 14% esketamine solution in each nostril at Time 0and repeated every 5 minutes x2 (total dose 84 mg)

After providing written informed consent, subjects were evaluated fromDays −21 to Day −2 during the screening phase to determine eligibilityfor participation, which included review of the inclusion and exclusioncriteria. All subjects were to meet the inclusion/exclusion criteriabefore admission to the study center for each treatment period. Subjectswere admitted into the study center on Day −1 of each period and weredischarged from the study center after collection of the final 24-hourPK sample on Day 2 of each treatment period. On Day −1 of the firsttreatment period, eligible subjects practiced self-administering aclear, colorless intranasal placebo solution for administration (waterfor injection with 0.001 mg/mL [0.0001%] of denatonium benzoate) in asemi-reclined position using devices identical to those used foresketamine administration. On Day 1 of each treatment period, subjectsself-administered each intranasal regimen of esketamine (see Section1.5, Dosage and Administration).

Pharmacokinetic blood samples for measurement of esketamine andnoresketamine concentrations in plasma were collected from predose untilup to 24 hours after each intranasal esketamine regimen on Day 1 of eachperiod.

The subjects returned to the study center 11 (±2) days after the lastdose of study medication for end-of-study assessments. Alternatively,the end-of-study assessments were conducted at the time of earlywithdrawal. The end of the study was the date of the last visit for thelast subject participating in the study. The total study length, fromthe screening phase through Follow-up, was up to 63 days.

Study Design Rationale

-   -   Study Agent: Esketamine has a higher affinity to the NMDA        receptor, thus reducing the required drug load and potentially        producing a more rapid recovery of cerebral functions and less        unpleasant psychotomimetic effects than racemic R-ketamine and        ketamine, respectively;    -   Study Population: A sample size of 12 subjects was expected to        be sufficient to adequately characterize the PK of each        intranasal esketamine regimen based on the variability reported        in previous studies with intranasal ketamine and was considered        to be representative of the profile in respective subjects with        TRD who will enroll in future clinical studies;    -   Study Design: A screening phase up to 21 days provided adequate        time to assess subject eligibility per inclusion/exclusion        criteria for the study and the post-treatment Follow-up Visit at        11 (±2) days facilitated assessment to assess safety and        tolerability of the subjects. Randomization was used to avoid        bias in the assignment of subjects to a treatment sequence group        and to increase the likelihood that known and unknown subject        attributes (e.g., demographic and baseline characteristics) were        evenly balanced across treatment sequences. The crossover design        reduced the total number of subjects to be enrolled in the study        and permitted within-subject comparisons;    -   Dose and Administration: The present study used intranasal        esketamine dose regimens lower than the IV esketamine regimens        typically used for induction and maintenance of anesthesia. The        doses were expected to be well-tolerated based on the published        studies;    -   Pharmacokinetics: The 24-hour postdose blood sampling interval        was sufficient to evaluate the single-dose PK of both esketamine        and its metabolite noresketamine.

1.2. Study Population

Fourteen healthy adult Caucasian subjects were enrolled, with similarnumber of subjects of each sex to have a similar ratio of men to women.Healthy men and women between 20 to 55 years of age, inclusive, with abody mass index (BMI) between 18 to 28 kg/m², inclusive and a bodyweight not less than 50 kg were enrolled in this study. Subjects had asystolic blood pressure between 90 mmHg to 145 mmHg, inclusive, and adiastolic blood pressure no higher than 90 mmHg, normal sinus rhythm, apulse rate between 45 to 90 beats per minute, a QTc interval s450milliseconds (msec), a QRS interval of s120 msec, a PR interval <210msec, and an ECG morphology consistent with healthy cardiac conductionand function. Per protocol, subjects did not have a history of suicidalor homicidal ideation, significant primary sleep disorder, or anycontraindication to the use of ketamine or esketamine.

Removal of subjects from therapy or assessment reasons for subjectwithdrawal from the study could include the following:

-   -   lost to follow-up;    -   withdrawal of consent;    -   subject not in compliance with requirements of the study,        including inclusion criteria, exclusion criteria, and        prohibitions and restrictions;    -   discontinuation of study treatment (final assessments were        obtained). A subject was to be discontinued from study treatment        if:    -   the investigator believed that for safety reasons (e.g., AE) it        was in the best interest of the subject to stop treatment    -   the subject became pregnant.

If a subject was lost to follow-up, every possible effort was to be madeby the study center personnel to contact the subject and determine thereason for discontinuation. The measures taken to follow up were to bedocumented.

If a subject withdrew prior to completing the study, the reason forwithdrawal was to be captured on the case report form (CRF) and in thesource document. Study agent assigned to

the withdrawn subject was not to be assigned to another subject. Atleast 12 subjects (including 4 of each sex) had to complete the studyprocedures of all treatment periods, including the 24-hour PK bloodsample collections, and the end-of-study evaluations. Subjects whowithdrew were to be replaced preferably with a subject of the same sexto complete the requisite 12 subjects per treatment.

Treatment Compliance

Study agent was self-administered in the controlled environment of aclinical research center, and the direct observation of theadministration of the study agent by study staff ensured compliance withstudy requirements. The date and time of each study agent administrationwas recorded in the CRF.

Prior and Concomitant Therapy

Throughout the study, prescription or nonprescription medication otherthan the study agent (including vitamins and herbal supplements;vasoconstrictors and decongestants that are administered by theophthalmic or intranasal routes) were prohibited, except foracetaminophen, oral contraceptives, and hormone replacement therapy. Theuse of acetaminophen was allowed until 3 days before each study agentadministration.

Throughout the study, a maximum of 3 doses per day of 500 mgacetaminophen, and no more than 3 g per week, was allowed for thetreatment of headache or other pain. If acetaminophen was used, the doseand dosage regimen and the reason for use were to be captured in theCRF.

Women using hormonal contraceptives as a means of birth controlcontinued to use the same hormonal contraceptives throughout the study.Women using hormone replacement therapy continued to use the samehormone replacement therapy throughout the study.

The sponsor was to be notified immediately if prohibited therapies wereadministered. All medications taken by a subject (prescription ornonprescription) that were not the study agent were documented in theconcomitant therapy section of the CRF. These included medications taken30 days before, during, and through the end-of-study visit (9 to 13 daysafter the last study agent administration).

1.3. Study Drug Information

Intranasal esketamine and placebo for practice administration weresupplied by the sponsor in a dual nasal spray device. Each devicecontained 200 μL and delivered 16.14 mg esketamine hydrochloride (14 mgesketamine base) or 0.1 μg of denatonium benzoate per 100 μL spray,respectively. The study agent information is given in Table 167:

TABLE 167 Study agent name Description, dose and mode of administrationEsketamine 161.4 mg/mL esketamine hydrochloride clear, colorlessintranasal solution Esketamine placebo Clear, colorless intranasalsolution of water for injection with a bittering agent (denatoniumbenzoate) at a final concentration of 0.001 mg/mL

1.4. Randomization and Blinding

This was an open-label study; therefore, no blinding of treatment wasperformed. Each intranasal dose regimen was labeled with therandomization code by site personnel and administered in an open-labelmanner.

If subjects were replaced, replacement subjects were assigned to thesame treatment sequence as the subjects they were replacing. Replacementfor subjects started with Period 1.

1.5. Dosage and Administration

Subjects self-administered intranasal esketamine in an open-label,crossover manner. They received the esketamine regimens over 3 treatmentperiods (i.e., 1 treatment per period, Table 168), as specified bytreatment sequences (Table 166). The regimens differed in the number ofsprays to achieve the total dose and the total esketamine doseadministered.

TABLE 168 Description of Treatments for Subjects Day 1 of Each PeriodTreatment Regimen Administration Total Total +5 +10 AdministrationNumber of Total Description^(a, b) Time 0 min min Interval SpraysDose^(b) Periods 1 and 2 A 1 spray of X — — — 2 28 mg 14% esketaminesolution in each nostril at Time 0 B 1 spray of X X —  5 min 4 56 mg 14%esketamine solution in each nostril at Time 0 and repeated in 5 minutesPeriod 3 C 1 spray of X X X 10 min 6 84 mg 14% esketamine solution ineach nostril at Time 0 and repeated every 5 minutes × 2 ^(a)Time 0 isdefined as the time of the first 100-μL spray. Sprays to each nostrilshould be delivered in rapid succession at the scheduled time points(i.e., there should be no waiting between sprays in each nostril at eachtime point). Subjects must be in a semi-reclined position whenadministering the sprays and remain reclined for at least 10 minutesafter the last spray. ^(b)Esketamine concentration (percent esketaminesolution) and Total Dose are expressed as esketamine base.

The intranasal esketamine regimens were self-administered under thedirect supervision of the Investigator or designee using the modifiedinstructions provided to the site (i.e., in a semi-reclined position forat least 10 minutes after the last spray; sniffing encouraged afterdosing).

Food was restricted for at least 8 hours starting from the eveningbefore dosing until 2 hours after each esketamine administration.Drinking of water or any other permitted beverage was restricted from 30minutes before the first nasal spray and until 30 minutes after the lastnasal spray of a given regimen. At approximately 2 hours after the lastnasal spray dosing, subjects in all 3 treatment periods were required todrink 180 to 240 mL of water.

1.6. Study Evaluations and Statistical Methods 1.6.1. PharmacokineticEvaluations 1.6.1.1. Sample Collection and Handling

Blood samples (4 mL each) for determination of esketamine andnoresketamine plasma concentrations were collected into the appropriatecollection tube (e.g., Vacutainer®) at timepoints 0.00, 0.12, 0.20,0.37, 0.53, 0.67, 0.83, 1.00, 1.25, 1.50, 2.00, 3.00, 4.00, 6.00, 9.00,12.00, 18.00, and 24.00 h. The total amount of blood to be drawn forclinical laboratory tests and PK evaluations is approximately 327 mL.

The exact date and time of sampling was recorded in the CRF, asappropriate. Before processing, the tubes were gently inverted 8 to 10times to afford mixing, and were placed in a cryoblock (in an uprightposition) or in an ice water mixture to the approximate height of theblood in the tube. The blood samples were centrifuged within 60 minutesof collection in a clinical centrifuge at 1,300 g (about 2,500-3,000rpm) for 10 minutes at 5° C. to yield approximately 1.8 mL of plasmafrom each 4-mL whole blood sample. All separated plasma was immediatelytransferred (equally divided) into 2 prelabeled polypropylene storagetubes with a dean, disposable glass or polyethylene pipette, while usinga new pipette for each sample. One tube was labeled “esketamine, main”and the second tube “esketamine, back-up”. The plasma samples werestored in an upright position, at −20° C. or lower until transferred tothe bioanalytical facility. The time between blood collection andfreezing the plasma was not to exceed 2 hours.

1.6.1.2. Bioanalytical Procedures

Plasma samples were analyzed for esketamine and noresketamineconcentrations using the validated, specific and sensitive liquidchromatography coupled to tandem mass spectrometry (LC-MS/MS) achiralmethod of Example 8.

1.6.1.3. Pharmacokinetic Parameters

Serial PK blood samples (4 mL each) were collected for a 24-hour periodfrom each subject (Periods 1, 2, and 3). Noncompartmental PK parametersof esketamine and its metabolite noresketamine estimated from plasmadata included:

-   -   C_(max) maximum plasma concentration during a dosing interval        t_(max)    -   t_(max) time to reach the maximum plasma concentration    -   AUC_(last) area under the plasma concentration-time curve from        time 0 to time of the last quantifiable concentration    -   AUC_(∞) area under the plasma concentration-time curve from time        0 to infinite time calculated as the sum of AUC_(last) and        C_(last)/λ_(z), in which C_(last) is the last observed        quantifiable concentration    -   t_(1/2,λ) elimination half-life associated with the terminal        slope (λ_(z)) of the semilogarithmic drug concentration-time        curve, calculated as 0.693/λ_(z)    -   λ_(z) first-order rate constant associated with the terminal        portion of the curve, determined as the negative slope of the        terminal log-linear phase of the drug concentration-time curve

1.6.4. Statistical Methods 1.6.4.1. Sample Size

At least 12 subjects (including 4 of each sex) had to complete the studyprocedures of all treatment periods, including the 24 hour PK bloodsample collections, and the end-of-study evaluations. Subjects whowithdrew were replaced, preferably, with a subject of same sex tocomplete the requisite 12 subjects per treatment. Based on a previouslycompleted study, the intersubject coefficient of variation for C_(max)and AUC of intranasal racemic ketamine was estimated to be at least 55%.Assuming an intersubject coefficient of variation of 55% for PKparameters of esketamine, a sample size of 12 subjects was sufficient toensure that the estimate of the mean PK parameters of esketamine fellwithin 71% and 142% of the true value with 95% confidence.

1.6.4.2. Initial Subject Characteristics

For all subjects who received at least 1 dose of study agent,descriptive statistics (mean, standard deviation [SD], median, minimum,maximum) were performed for age, BMI, weight, and height Sex and racewere listed and tabulated.

1.6.4.3. Pharmacokinetic Analysis

For esketamine and noresketamine, data were listed for all subjects withavailable plasma concentrations. All plasma concentrations below thelowest quantifiable concentration in a sample or missing data werelabeled as such in the concentration data presentations.

Concentrations below the lower quantifiable concentration were treatedas zero when calculating PK parameters and summary statistics. Allsubjects and samples excluded from the analysis were to be clearlydocumented.

Descriptive statistics were used to summarize plasma esketamine andnoresketamine concentrations at each sampling timepoint. The analysisincluded data from all subjects with available data from a least 1 doseof study agent. Plasma concentration data at each timepoint weresummarized with mean, median, minimum, maximum, SD, and percentcoefficient of variation for all subjects who received at least 1 doseof study agent.

The following key parameters of esketamine and noresketamine in plasmawere calculated using noncompartmental methods and actual samplingtimes: C_(max), t_(max), AUC_(last), AUC_(∞), t_(1/2,λ), and λ_(z).

All estimated PK parameters of esketamine and noresketamine weresummarized for each treatment with mean, median, minimum, maximum, SD,percent coefficient of variation for each treatment provided.

2. Subject and Treatment Information 2.1. Subject Disposition and StudyCompletion/Withdrawal Information

Initially a total of 14 Caucasian subjects were enrolled and treatedwith esketamine with 7 subjects randomized to each treatment sequence.Of these 14 subjects, 13 subjects completed the study, with 7 subjectsin each treatment sequence (ABC and BAC). One subject discontinued thestudy; the subject did not meet entry criteria for Period 2, due to apositive result for the urine drug screen at Period 2 check in.

2.2. Demographic and Baseline Characteristics

Demographic and baseline characteristics of subjects who received a doseof esketamine are presented in (Table 169).

TABLE 169 Demographic and Baseline Characteristics; Safety Analysis SetABC BAC Total Subjects treated 7 7 14 Age (years) N 7 7 14 Mean (SD)32.3 (8.20) 33.9 (11.75) 33.1 (9.77) Median Range 31.0 (24; 48) 28.0(22; 50) 30.0 (22; 50) Sex N 7 7 14 Female 1 (14.3%) 4 (57.1%) 5 (35.7%)Male 6 (85.7%) 3 (42.9%) 9 (64.3%) Race 7 7 14 Asian 0 0  0 White 7(100.0%) 7 (100.0%) 14 (100.0%) Ethnicity N 7 7 14 Not Hispanic orLatino 7 (100.0%) 7 (100.0%) 14 (100.0%) Baseline Weight (kg) N 7 7 14Mean (SD) 79.39 (7.866) 67.47 (11.265) 73.43 (11.196) Median   79.50  63.60   75.15 Range (68.1; 93.1) (56.9; 87.2) (56.9; 93.1) BaselineHeight (cm) N 7 7 14 Mean (SD) 181.79 (7.793) 170.93 (5.992) 176.36(8.737) Median  179.90  168.30   175.35 Range (175.0; 197.6) (164.0;181.4) (164.0; 197.6) Baseline BMI (kg/m²) N 7 7 14 Mean (SD) 24.00(1.489) 22.97 (2.308) 23.49 (1.941) Median   24.10   22.40   23.30 Range(21.6; 26.0) (20.6; 26.5) (20.6; 26.5) ABC = Esketamine 28 mg/Esketamine56 mg/Esketamine 84 mg BAC = Esketamine 56 mg/Esketamine 28mg/Esketamine 84 mg

2.6. Extent of Exposure

The subjects received all 3 different single-dose regimens of intranasalesketamine (Treatments A, B, and C) during Periods 1, 2, and 3 as perthe randomized sequence. Sprays were administered as follows:

-   -   in Treatment A, 28 mg at Time 0;    -   in Treatment B, 28 mg at Time 0 and 5 minutes each (totaling 56        mg); and    -   in Treatment C, 28 mg at Time 0, 5, and 10 minutes each        (totaling 84 mg).        The discontinued subject received the study agent as follows:    -   The subject of Treatment Sequence 2 received esketamine 28 mg at        Time 0 and 5 minutes (totaling 56 mg) at Period 1, Day 1.

3. Pharmacokinetic Results

Plasma samples were analyzed for the concentrations of esketamine andnoresketamine using a validated, specific, and sensitive liquidchromatography-tandem mass spectrometry (LC-MS/MS) method as describedin Example 8. A total of 14 Caucasian subjects (9 men, 5 women) wereenrolled in this study and received at least 1 dose of 28 mg, 56 mg, or84 mg of esketamine. One subject withdrew from the study aftercompleting the first treatment period in which the subjectself-administered Treatment B (esketamine 56 mg).

In addition, one Treatment A (esketamine, 28 mg, predose) sample wasexcluded from the entire PK analysis of esketamine and noresketamine asthey were taken at time of withdrawal.

The terminal phase of the esketamine concentration-time profile couldnot be reliably estimated with either an R^(adj)2 value <0.900 and/or anAUC_(∞) extrapolation >20%. As a result, esketamine AUC_(∞),AUC_(∞)/Dose, t_(1/2), and λ_(z) were excluded from the descriptivestatistics for the 3 subjects, i.e., Treatment A (esketamine 28 mg),Treatment B (esketamine 56 mg), and Treatment C (esketamine 84 mg).

The terminal phase of the noresketamine concentration-time profile couldnot be reliably estimated with either an R² _(adj) value <0.900 and/oran AUC_(∞) 0 extrapolation >20%. As a result, noresketamine AUC_(∞),AUC_(∞)/Dose, t_(1/2), and λ_(z) were excluded from the descriptivestatistics for 2 subjects, i.e., Treatment B (esketamine 56 mg) andTreatment C (esketamine 84 mg).

In addition, the metabolite to parent ratio for AUC_(∞) was excludedfrom descriptive statistics as AUC_(∞) was excluded from the descriptivestatistics for either esketamine or noresketamine for 5 subjects, i.e.,Treatment A (esketamine 28 mg), Treatment B (2 subjects; esketamine 56mg), and Treatment C (2 subjects; esketamine 84 mg).

All PK parameters were calculated using the actual times of bloodsampling.

Pharmacokinetic Results

Mean plasma concentration-time profiles of esketamine and noresketamineare presented in FIGS. 80 and 81, respectively.

Following intranasal administration, maximum concentrations (C_(max)) ofesketamine were reached with median t_(max) ranging from 0.67 to 0.83hours in healthy subjects, respectively, across the 3 intranasalregimens of esketamine (28, 56, and 84 mg) (Table 170). Maximumconcentrations of metabolite noresketamine were observed later withmedian t_(max) ranging from 1.25 to 1.5 hours in healthy subjects,respectively (Table 171).

For esketamine C_(max), variability (expressed as percent coefficient ofvariation) across the 3 treatment groups ranged from 35.7% to 36.7%. Foresketamine AUC (both AUC_(last) and AUC_(∞)), variability ranged from25.0% to 30.4%. Between-subject variability for noresketamine C_(max)ranged from 25.8% to 33.7% in subjects. For noresketamine AUC (bothAUC_(last) and AUC_(∞)), variability ranged from 17.0% to 21.3% insubjects.

Plots of esketamine C_(max) or AUC versus total body weight wereconstructed for each dose level. Similar plots were prepared for themetabolite. The results suggest there is a trend towards a decrease inesketamine and noresketamine C_(max) and AUC with an increase in bodyweight. The strength of the trends varied across the dose groups.

Based on visual inspection, the mean C_(max), AUC_(last), and AUC_(∞)for esketamine and mean C_(max) for noresketamine increased withincreasing doses in a less than dose-proportional manner (FIGS. 80 and81 and Tables 170 and 171). The mean noresketamine AUC_(last) andAUC_(∞) values appeared to increase in a manner that was proportional tothe esketamine dose.

Mean t_(1/2) of esketamine ranged from 7.11 to 7.25 hours in thesubjects (Table 170).

TABLE 170 Mean (SD) Esketamine Pharmacokinetic Parameters C_(max)t_(max) ^(a) AUC_(last) AUC_(∞) t_(1/2) Subgroup/Treatment (ng/mL) (h)(h*ng/mL) (h*ng/mL) (h) A: Esketamine 49.7 0.67 128 136^(d) 7.25^(d) 28mg (n = 13) (18.1) (0.20-1.50) (31.8)   (33.9)^(d) (1.19)^(d) B:Esketamine 74.1 0.67 216 222^(b) 7.25^(b) 56 mg (n = 14) (27.2)(0.20-1.25) (61.5)   (59.9)^(b) (1.67)^(b) C: Esketamine 103 0.83 310329^(d) 7.11^(d) 84 mg (n = 13) (36.8) (0.20-1.50) (92.0) (100)^(d)(1.78)^(d) ^(a)Median (Min-Max), ^(b)n = 13, ^(c)n = 11, ^(d)n = 12

Mean t_(1/2) of noresketamine ranged from 7.48 to 7.74 hours in thesubjects (Table 171).

TABLE 171 Mean (SD) Noresketamine Pharmacokinetic Parameters Subgroup/C_(max) AUC_(last) AUC_(∞) Metabolite/Parent Ratio Treatment (ng/mL)t_(max) ^(a) (h) (h*ng/mL) (h*ng/mL) t_(1/2) (h) C_(max) AUC_(last)AUC_(∞) A: 92.8 1.25 454 508  7.74 1.96 3.62 3.80^(b) Esketamine (24.6)(0.67-2.00)   (89.0) (108)  (1.66) (0.445) (0.589) (0.739)^(b) 28 mg (n= 13) B: 154 1.50 851 924^(c) 7.71^(c) 2.28 4.07 4.22^(b) Esketamine(39.8) (0.83-3.00) (177) (195)^(c) (1.59)^(c) (0.818) (0.876)(0.991)^(b) 56 mg (n = 14) C: 241 1.50 1287  1392^(b)  7.48^(b) 2.554.32 4.46^(d) Esketamine (81.1) (1.25-3.00) (219) (252)^(b) (1.47)^(b)(0.976) (0.871) (1.06)^(d) 84 mg (n = 13)

The plasma concentrations of noresketamine were generally higher,relative to the parent compound. For C_(max), the mean ratios ofnoresketamine to esketamine ranged from 1.96 to 2.55. For AUC_(last),the mean ratios ranged from 3.62 to 4.32. For AUC_(∞), the mean ratiosranged from 3.80 to 4.46 (Table 171).

Conclusion:

Mean plasma esketamine C_(max) and AUC increased in a less thandose-proportional manner across the 28-mg, 56-mg, and 84-mg intranasaldose regimens of esketamine.

Example 10

The data herein was assembled from 14 Phase 1 studies; each Phase 1study was performed similarly to the study outlined in Example 9 inwhich the PK of esketamine was assessed.

The PK parameters of esketamine including T_(max), C_(max), AUC_(last),and terminal t_(1/2) after administration of 28 mg, 56 mg, or 84 mg ofnasal esketamine are provided in Table 172. The t_(max) of esketaminewas typically observed at 20 to 40 minutes, 30 to 45 minutes, or 30 to50 minutes after the first nasal spray of a 28 mg, 56 mg, or 84 mg ofesketamine, respectively (i.e., approximately 20 to 40 minutes after thelast spray of a given dose). A dose-dependent, linear increase in meanesketamine C_(max) and AUC_(last) is evident (FIGS. 82A and 82B).

TABLE 172 Pharmacokinetic Parameters of Esketamine in Young AdultSubjects After a Single Dose of Esketamine Nasal Spray T_(max) C_(max)AUC_(last) Terminal t_(1/2) Esketamine (h) (ng/mL) (ng*h/mL) (h) 28 mg0.33-0.67  49.7-70.5 128-183 7.25-16.5  (n = 64) (n = 64) (n = 64) (n =61) 56 mg 0.50-0.77 71.8-117 216-317 6.8-9.83 (n = 86) (n = 86) (n = 86)(n = 83) 84 mg 0.53-0.83 95.0-164 310-489 6.6-12.0  (n = 167)  (n = 167) (n = 167)  (n = 150) Range of median values are provided for T_(max);range of mean values provided for C_(max) and AUC_(last).

After esketamine C_(max) was reached following nasal administration, thedecline in concentrations in plasma is rapid for the initial 2 to 4hours and then more gradual. The esketamine mean terminal t_(1/2) rangedfrom 7 to 12 hours. The median terminal t_(1/2) in this study was 10.7hours.

Example 11—Approved Drug Product Label

An approved drug product label:

While the foregoing specification teaches the principles of the presentinvention, with examples provided for the purpose of illustration, itwill be understood that the practice of the invention encompasses all ofthe usual variations, adaptations and/or modifications as come withinthe scope of the following claims and their equivalents.

What is claimed is:
 1. A method of treating major depressive disorder ina human patient in need thereof based on a dosing regimen, said regimenhaving an induction phase and, optionally, a subsequent maintenancephase, wherein the induction phase has a duration of 4 weeks, the methodcomprising: intranasally administering an aqueous formulation comprisingesketamine and/or a pharmaceutically acceptable salt thereof in theinduction phase to provide a therapeutically effective amount of about56 mg or about 84 mg of esketamine per induction phase treatment sessionto the patient, wherein the induction phase treatment session occurs ata frequency of twice weekly during the induction phase; and intranasallyadministering an aqueous formulation comprising esketamine and/or apharmaceutically acceptable salt thereof in the maintenance phase toprovide a therapeutically effective amount of about 56 mg or about 84 mgof esketamine per maintenance phase treatment session to the patient,wherein the maintenance phase treatment session occurs at a frequency ofonce weekly or once every other week during the maintenance phase; andwherein if the patient misses one or more treatment sessions in theinduction phase or the maintenance phase, and there are no worsening ofdepression symptoms, administering a next treatment session that wouldhave followed the missed treatment session based on the regimen.
 2. Themethod of claim 1, wherein if there is a worsening of depressionsymptoms following a missed treatment session during the maintenancephase, returning to a previously higher frequency of treatment sessionbefore the missed treatment session.
 3. The method of claim 2, whereinthe missed treatment session occurs during once weekly treatmentsessions, and the patient is returned to twice weekly treatmentsessions.
 4. The method of claim 2, wherein the missed treatment sessionoccurs during once every other week treatment sessions, and the patientis returned to once weekly treatment sessions.
 5. The method of claim 1,further comprising adjunctive treatment with a therapeutically effectiveamount of one or more antidepressants during the induction phase or themaintenance phase.
 6. The method of claim 1, further comprisingadjunctive treatment with a therapeutically effective amount of one ormore antidepressants during the induction phase and the maintenancephase.
 7. The method of claim 6 wherein the one or more antidepressantsis an oral antidepressant.
 8. The method of claim 1, wherein the majordepressive disorder is major depressive disorder with suicidal ideationor behavior.
 9. The method of claim 1, wherein the major depressivedisorder is treatment resistant depression.
 10. The method of claim 1,wherein the aqueous formulation comprises esketamine hydrochlorideduring the induction phase and maintenance phase.